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Statewide coordinated statement of need and comprehensive strategic plan : Ryan White Part B services for the state of Oklahoma.

Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
85
CHAPTER 9: Profile of Ryan White Funded Providers by Service Category
Ryan White Providers and Services
The state has two primary “hubs” of service providers—Oklahoma City and Tulsa. Each city has a Part C clinic as well as Part B providers.
Description of Oklahoma City Part B Providers
• The University of Oklahoma Health Sciences Center-Infectious Disease Unit provides comprehensive HIV specialty medical care and coordinated access to health care treatment and support services for infected children, adolescents, men and women with HIV/AIDS, and their affected families residing in the 405/580 area codes (through a combination of Part B, C, and D funding). Part B funded services include laboratory, specialty medical care, medical case management, mental health services, local APA, and treatment adherence. OUHSC also promotes HIV prevention, education, and counseling and testing. These programs link those HIV positive persons who are out-of-care into medical treatment and support services, and decrease the acuity level of these persons.
• The Regional AIDS Intercommunity Network (RAIN Oklahoma) was formed by the January 2005 merger of the Regional AIDS Interfaith Network and CarePoint. Both organizations have been actively engaged in providing services to Oklahomans impacted by HIV/AIDS for well over a decade (RAIN was founded in 1991 and CarePoint in 1993). The merged agency operates from offices in Oklahoma City, Tulsa and Lawton, and provides a continuum of services including HIV prevention education, testing, outreach case management and non-medical case management, housing assistance, nutritional services, and volunteer care teams to clients Statewide. Part B funds outreach case management and non-medical case management in the Oklahoma City and Lawton RAIN offices.
Agency
Primary Medical Care/Labs
Specialty Medical Care
Substance
Abuse/
Mental Health
Dental
Case
Management
Transport-
ation
Local APA
TX
Adherence
Outreach CM
Red Rock BHC
X
RAIN OK
X
X
X
X
RAIN Lawton
X
X
Tulsa C.A.R.E.S.
X
X
OUHSC-IDI
X
X
X
X
X
X
OSU CHS-COM
X
X
X
X
X
X
X
Total
3
2
3
3
5
2
2
1
3 Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
86
• Red Rock North Behavioral Health Services provides mental health care and the continuum of care for HIV-positive individuals.
Description of Tulsa Area Part B Providers
• The Oklahoma State University-Center for Health Sciences-College of Osteopathic Medicine’s Internal Medicine Specialty Services Program is responsible for providing comprehensive, integrated HIV prevention, primary medical and specialty care and care coordination services for individuals living with HIV/AIDS residing in the 918 area code (through a combination of Part B, Part C and CDC funding). Part B funded services include laboratory, specialty medical, medical case management, local APA, dental and medical transportation services.
• The Tulsa Center for AIDS Resources, Education and Support (Tulsa C.A.R.E.S.) provides services to meet the special needs of those affected by HIV and AIDS. The case management program forms the hub of the direct care service delivery system in the 918 area code. Part B funds support non-medical case management.
Coordination and Linkage with Other HIV Programs
Ryan White Part A: No Part A Eligible Metropolitan Area (EMA/TGA) exists in Oklahoma.
Ryan White Part B: The Part B service providers are RAIN Oklahoma, RAIN Lawton, Tulsa C.A.R.E.S., Red Rock Behavioral Health Services and OUHSC and OSU-CHS-COM.
Ryan White Part B funding is also being used for the HIV Drug Assistance Program (HDAP), the Home Health Care Program and the Health Insurance Assistance Program (HIAP).
Ryan White Part C: Two (2) Part C programs exist in Oklahoma. The University of Oklahoma Health Sciences Center (OUHSC) is the only program in the 54-county Western region of Oklahoma. Oklahoma State University Center of Health Sciences College of Osteopathic Medicine is the Part C grantee for the 23 counties in the Eastern region of the state.
Ryan White CARE Act Part D: OUHSC is the Part D grantee.
AETC: OUHSC is the AETC grantee.
Part F: The dental reimbursement program is administered by OUHSC College of Dentistry.
HIV Prevention: The Oklahoma State Department of Health (OSDH) receives funding for HIV Prevention services from the Centers for Disease Control and Prevention (CDC).
Other:
o HUD-SHP (Housing and Urban Development – Supportive Housing Program)
o HOPWA (Housing Opportunities for People With AIDS)
o Department of Rehabilitative Services Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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CHAPTER 10: Demographics of Part B Clients
Table 39: Comparison of 2007 HIV/AIDS Prevalence & 2007 Part B PLWHA Clients
2007 Epi Profile
2007 Part B Clients
Demographic Group/ Exposure Category
PLWHA as of 12/07
Demographic Group/
Exposure Category
PLWHA as of 12/07
Gender
#
% of Total
Gender
#
% of Total
Male
5011
83.45%
Male
1,458
81.2%
Female
994
16.55%
Female
330
18.4%
Transgender
-
-
Transgender
6
0.3%
Total
6,005
100%
Total
1795
100.0%
Race/ Ethnicity
#
% of Total
Race/ Ethnicity
#
% of Total
2,669
44.45%
White, not Hispanic
1001
55.8%
White, not Hispanic
892
14.85%
African-American, not Hispanic
356
19.8%
African-American, not Hispanic
218
3.63%
Hispanic
149
8.3%
Hispanic
0
0%
Asian/PI
8
.5%
Asian/PI
250
4.16%
American Indian/A.N.
127
7.1%
American Indian/A.N.
0
0%
Multi-race
131
7.3%
Multi-race
1,974
32.87%
Other/Unknown
23
1.3%
Unknown
Total
6,005
100%
Total
1795
100.0% Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
88
2007 Epi Profile Demographic Group/
PLWHA as of 12/07
2007 Part B Demographic Group/Exposure
PLWHA as of 12/07
Age at Diagnosis (Years)
#
% of Total
Age at Diagnosis (Years)
#
% of Total
<13 years
48
0.80%
<13 years
2
0.11%
13-24 years
794
13.22%
13-24 years
58
3.23%%
25-34 years
2,245
37.39%
25-34 years
314
17.49%
35-44 years
2,035
33.89%
35-44 years
735
40.95%
45-54years
720
11.99%
45-54years
572
31.87%
55-64
140
2.33%
55-64
101
5.63%
65+
23
.38%
65+
13
0.72%
Total
6,005
100%
Total
1795
100%
Adult/Adolescent Exposure Category
#
% of Total
Adult/Adolescent Exposure Category
#
% of Total
MSM
3,019
50.3%
MSM
978
54.5%
IDU
714
11.9%
IDU
165
9.2%
MSM/IDU
662
11%
MSM/IDU
158
8.8%
Hemo/Coagulation Disorder
21
.35%
Hemo/Coag Disorder
4
0.2%
HET
679
11.3%
HET
409
22.8%
Blood Transfusion
42
0.7%
Blood Transfusion
7
0.4%
Risk Not Specified
816
13.6%
RNS/Other
69
3.9%
Total
6,005
100%
Total
1795
100%
Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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Table 39: Underrepresented Populations in Ryan White Funded Primary Medical Care
Special Population
Overall % in PLWHA
Comparison to ‘In Care’ Population %
Estimated Composition in Out of Care Group
1) African Americans
New AIDS 26% New HIV 32% PLWH 15.3 %
PLWA 15%
19.8% Part B
22.5% Part C
52%
2) Youth, 13-24 years & 20-29 years
New HIV 32.3% (among Youth ages 20-29 yrs) PLWH 22% (among Youth, ages 15-24 yrs)
Youth, ages 13-29 comprise 10.3% of Part B clients
Youth, ages 13-24 yrs comprise only 2.9% Part C clients
PLWH: 13-19 yrs: 73%; 20-29 yrs: 63%
PLWA: 13-19 yrs: 45%; 20-29 yrs: 42%
3) Hispanics
New AIDS 10.5% New HIV 7.1% PLWA 3.8% PLWH 3.4%
8.3% Part B clients
7% of Part C clients
64%
4) IDU
*New AIDS 22% New HIV 17% *PLWA 25% *PLWH 21%
18% of ‘combined’ Part B
18% of ‘combined’ Part C
unk
5) Rural PLWHA
Unknown
16% Part B Clients
Est. 20% Part C
54%
• Proportion of IDU total when combine IDU and MSM/IDU (Source: Column B: OK HARS data, 2007; Column C –2007 CAREWare Data; Column D: 2008 Unmet Needs Assessment)
African American PLWHA
In 2007, Blacks comprised 32% of the new HIV cases, yet there were only 19.8% African American PLWHA in the Ryan White Part B program’s Primary Medical Care service category. (2007 Ryan White CADR) Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
90
Out of Care/Unmet Need: The level of Unmet Need among African Americans is 2nd among race/ethnic groups at 52%, behind Hispanics at 64%, per a 2008 Oklahoma study.
Barriers to Care Entry: Barriers to care entry include the stigma associated with HIV infection, issues with disclosing risk behavior, concerns about funding of care, and historical misperceptions about antiretroviral therapy.
PLWHA Youth
In 2007, there were 10.3% Youth PLWHA (ages 13-29 years) in the Ryan White Part B program’s Primary Medical Care service category. (Oklahoma 2007 Ryan White CADR)
Out of Care/Unmet Need: Youth evidenced a substantially increased rate for being out of care in 2007, at 42%-73%, depending on HIV or AIDS status and age range (13-19 years versus 20-29 years) according to a 2008 Oklahoma Unmet Need study.
Barriers to Care Entry: Barriers listed by Youth include stigma, perception that they aren’t ‘sick’, and fears related to HIV medications. These fears appear contradicted by their statements that HIV medications can resolve their infection despite delayed entry into treatment.
Hispanic PLWHA
In 2007, there were 8.3% Hispanic PLWHA in the Ryan White Part B program’s Primary Medical Care service category, while Hispanics comprised 10.5% of all new AIDS cases. (Oklahoma 2007 Ryan White CADR)
Out of Care/Unmet Need: Hispanics recorded the highest percent of unmet need or election to stay out of care among all races/ethnicities despite an HIV-positive diagnosis at 64% in 2007.
Barriers to Care Entry: Reasons for the decision not to enter care include undocumented citizenship status, lack of financial resources, stigma related to HIV, and issues surrounding the desire to remain non-disclosed to their spouse and/or family about disease/same-sex relations.
IDU
In 2007, there were 9.2% IDU and 8.8% MSM/IDU (for a total of 18%) in RW funded Part B services, yet IDU and MSM/IDU comprised 17% of HIV incidence, 22% of AIDS incidence, 25% of AIDS prevalence and 21% of HIV prevalence in 2007. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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Barriers to care Entry: Barriers for IDU and substance abusers include continued substance use/abuse and fear of legal entanglements.
Rural PLWHA
In 2007, Rural PLWHA comprised 16% of the Part B funded service delivery system.
Out of Care/Unmet Need: Rural PLWHA, residing in non-MSA localities throughout the state, comprised 54% of the out of care population (compared to the state average of 48%).
Barriers to care Entry: Many barriers act as obstacles to care for Rural PLWHA including transportation difficulties, stigma, and fears of disclosure and lack of confidentiality.
Males, Females, MSM, Heterosexual and American Indians are all ‘In Care’ in proportions that reflect their proportionate representation in the local epidemic.
SECTION II. WHERE DO WE NEED TO GO: WHAT SYSTEM OF CARE DO WE WANT?
Introduction to Section II:
The OHPC plans to focus its actions and those of its partners over the next three years on the further refinement of an ideal continuum of care for all PLWHA in Oklahoma. Efforts to achieve this ideal will result in a continuum that shortens the time between diagnosis and entry into care, facilitates earlier testing and treatment and reduces transmission of the virus to others, lengthens the time between entry into care and transition to AIDS-defined status, reduces the number and severity of complications and episodes of illness and, finally, lengthens the time between HIV diagnosis and death from the virus. Through careful consideration of Oklahoma PLWHAs’ environment, population characteristics, history, needs, care resources, service gaps and barriers to care, the OHPC has developed an ideal continuum of care.
CHAPTER 11: Continuum of Care for High Quality Core Services/Shared Vision & Values
The Mission of the Statewide Coordinated Statement of Need (SCSN): is to identify epidemiological trends, common unmet needs and barriers for persons living with HIV/AIDS throughout Oklahoma and to promote a shared vision for effective planning and coordination of treatment and care services across the state.
OHPC Vision Statement: Over the next three years, the community will enhance (or increase access to) a coordinated system of HIV/AIDS care (treatment) and prevention in order to improve the quality of life for people living with HIV/AIDS in Oklahoma. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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The continuum of care in Oklahoma is defined by those services directly linking newly diagnosed and people living with HIV and AIDS to primary medical care and support services. Services with the highest ranking throughout the prior three-year strategic plan timeframe relate directly to primary medical care entry and retention. (Core Medical Services ranked 1 through 5 in priority). Medical and social support services ranked 6-15 are services determined to facilitate entry into and retention in care based on findings of the 2006 triennial needs assessment.
Mission of the Oklahoma HIV Planning Council: To ensure active, diverse and substantive input and involvement of persons living with HIV and AIDS (PLWHA) in the HIV prevention and care planning processes for the State of Oklahoma. The Oklahoma HIV Planning Council is an important statewide advisory planning body of physicians, community leaders, State agency representatives, service providers, and consumers. Working in partnership with the Oklahoma State Department of Health, HIV/STD Service, they developed the goals of the SCSN and Comprehensive Plan, make recommendations as to the best utilization of the Ryan White Part B funds, and help to develop and maintain a comprehensive continuum of care for those living with HIV disease. After analyzing needs assessments, service barriers, and gaps in services, they submit an HIV service delivery plan for Oklahoma and evaluate these services for cost effectiveness and efficacy of meeting consumer needs. It is the policy and mission of the OHPC to ensure active, diverse and substantive input and involvement of persons living with HIV/AIDS (PLWHA) in the planning process. PLWHA have a unique understanding of service needs, which make them essential participants in the planning and oversight of services. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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OHPC TREATMENT ADHERENCE MCM PMC MENTAL HEALTH CARE SUBSTANCE ABUSE TREATMENT Non‐MedicalCM MEDICALTRANSP CONSUMERORAL HEALTH CARE MEDS OKLAHOMA Ryan White Part B Ideal Continuum of CareSPECIALTY MEDICAL CARELAB Other Ryan White Part C, D, F & Non‐RW Funding Streams: MCD, MCR, DHS OEPIC, DHS Advantage, etc Other Medical/ Support Services: 330b; Indian Health Services; MCD Transport: HOPWA; Section 8, Food stamps, etc PREVENTION, T & C & EIS/OUTREACH CM & REFERRAL LINKAGESOklahoma State Department of Health 2009‐2011 Comprehensive Plan
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SECTION III: HOW WILL WE GET THERE: HOW DOES OUR SYSTEM NEED TO CHANGE TO ASSURE AVAILABILITY OF AND ACCESSIBILITY TO CORE SERVICES?
CHAPTER 12: Planning within the State of Oklahoma
The purpose of this section is to provide a road map that will refine and continuously improve the Oklahoma HIV care and support services delivery system. The proposed care system has been created to be responsive to the changing needs of the epidemic and fill the service gaps of PLWHA who know their status and are not in care. The Plan effectively responds to HRSA/HAB’s over-arching goals ‘to increase access to care to 100% and reduce outcome disparities to 0%’. It provides guidance as to how our system needs to change to assure availability of and accessibility to core medical and other support services.
As the continuum of care in Oklahoma continues to evolve, core values and shared visions are utilized to guide and direct the service delivery planning process for PLWHA. Utilizing these guiding principles (Mission and Shared Vision) and other pertinent information such as the HRSA planning requirements, the Statewide Coordinated Statement of Need (SCSN), and results from the regional and statewide needs assessments, the OHPC formulated the following goals and objectives for the next three years. The following sections will include:
􀂾 A narrative description of the goals of the SCSN and Plan, and
􀂾 A summary table of each goal, accompanied by objectives and actions with
specified timeline and responsible party.
The central purpose of the Ryan White Part B funding is facilitating PLWHA access into and retention in care and ensuring that they are supported in adhering to their medical regimens. Therefore, at the core (center) of the model are both medical care and the supportive services that help PLWHA to engage with and remain in care.
Because it is important that these various medical and support services be delivered in a coordinated and consistent manner, the care circle is surrounded by services that facilitate or arrange access to medical and supportive services. This core of medical, supportive, and coordination services exists in the context of goals that promote access to care for all those living with HIV/AIDS and ensures that high-quality services are provided in a cost-effective manner. The entire continuum of care is specifically designed to result in improved health outcomes.
Extensive planning contributed to development of the updated comprehensive plan, with Ryan White and other service provider, community involvement and PLWHA input. Developing goals for the integrated 2009-2011 SCSN and Comprehensive Plan was a data-driven process. The preliminary goals presented in this document were developed based on consumer and provider input; epidemiologic and other data from the Oklahoma State Department of Health; detailed In Care and Out of Care consumer survey results from the 2006 Needs Assessment, and preliminary Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
95
results from the 2009 prevention prioritization process. Additional data sources include information from the last Statewide Comprehensive Statement of Need and Statewide Comprehensive Prevention Plan, with final input from the Planning Council.
The OHPC members and invited guests spent a day-long planning session to review and refine the short-term and long-term goals for the integrated SCSN and Comprehensive Plan. The Oklahoma HIV Planning Council is responsible for assuring that the plan’s goals are met with the suggested objectives and tasks assigned. In addition, in collaboration with OSDH,
the Care Committee is responsible for:
1) Implementing the specific tasks required to meet the goals;
2) Monitoring the tasks required to meet the goals using measurable indicators; and
3) Performing outcomes evaluation on the goals in the plan.
Cross Cutting Issues
Cross-cutting issues identified in the day-long statewide planning process and common to all Ryan White Program Parts across the State include extreme poverty, high levels of un-insurance, substantial co-morbidity, drug use, lack of transportation, lack of affordable housing, lack of knowledge about services available, stigma, discrimination, fears of disclosure and lack of confidentiality. Also noted was the continued high level of unmet need, the rising cases of HIV/AIDS among Youth, and the disproportionate impact among Blacks.
In addition to the findings already mentioned, several needs, gaps and challenges were also
Identified, as follows:
1) The need for integrated, interdisciplinary and co-located approaches to care and support services;
2) Multi-cultural, multi-disciplinary teams that integrate to the extent possible medical care, including specialty care, with mental health, substance use treatment, case management and other HIV- related support services can best manage the complex medical and social issues faced by PLWHA and their affected families. Ideally, services are co-located or, at a minimum, stronger working relationships are forged between programs.
3) The need for case management training in performing expanded behavioral risk assessment and risk reduction education that is age appropriate and culturally competent
4) The increased complexity of care and costs associated with multiple co-morbidities diagnoses (MH, SA, Hepatitis, STDs, diabetes and heart disease) which translates into an on-going need for cross-training of staff, co-location of services wherever feasible, and frequent case consultation.
5) Long distances to travel for rural PLWHA combined with weak public transportation infrastructure creates access barriers for rural PLWHA.
6) Shortage of dentists who accept Medicaid and need for expanded oral health services.
7) The need for stronger linkages between prevention and care – referrals and retention in care.
8) The need for community-based social marketing efforts to reduce stigma and inform consumers of benefits of testing, treatment and care.
9) The need for ongoing Provider staff education in cultural competency. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
96
10) The need for greater CM training in accessing all available third party resources.
11) The need for RW and non-RW provider training in facilitating client access to all available medical and support services.
12) The need for continued training in Data management systems and Quality Management & Evaluation
Conclusion
The steady expansion and changed demographics of the HIV epidemic, as well as improved survival time for people living with AIDS are placing increased stress on state and local health care systems. The State of Oklahoma, through this integrated SCSN and Comprehensive Plan document, outlines the need for collaboration among all Ryan White grantees. This collaboration is based on needs assessment findings, goals and objectives of the Oklahoma HIV Planning Council and evaluation/monitoring of HIV/AIDS providers. The overreaching goal for all Ryan White Parts is to link/re-engage in primary medical care those individuals who know their positive HIV status. As all of the Ryan White funded entities respond to the numerous challenges in delivering quality HIV care for an expanding patient population, the collaborative focus on reducing health care disparities, bringing the out of care in to care while maintaining a comprehensive continuum of care is critical. Only through ‘all Part’ collaboration can these challenges be overcome.
Narrative Summary of 2009 Service Delivery Goals
Goal 1: Improve Access to Health Care
An ideal, comprehensive care system ensures that geographical, socioeconomic, or infrastructure obstacles that prevent PLWHA from accessing that system are minimized or eliminated. A variety of regional and Statewide collaborative strategies, along with targeted marketing, outreach and early intervention programs are designed to overcome barriers to care, including PLWHA not knowing how or where to obtain care, not knowing what services are available through Ryan White, or lacking the knowledge or skills in how to navigate the benefits and services available in Oklahoma. EIS case management staff also serve those out of care by addressing their concerns about stigma and other issues that may keep them from seeking care. Outreach is strongly linked to early intervention services, with the goal of facilitating earlier access to care and shortening the interval between testing and care entry.
Only 52% of Oklahoma’s PLWHA have a met need for HIV primary medical care. Ensuring access to all needed core medical services, including adequate levels of Oral Health Care, acceptable and accessible Mental Health and Substance Abuse treatment services, and providing the necessary transportation assistance to access needed services represent top goals for the new plan. The measures of the efficacy of this HRSA strategy include the increasing number/percentage of the HIV-positive population (including each of the special populations) who are entering care each year, encouraging earlier entry into care and reducing time from Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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testing to care, and effectively retaining in care all special populations living with HIV disease in Oklahoma.
Goal 2: Eliminate Health Disparities
African Americans, Hispanics, Males, MSM, and Youth evidence an increasing and disproportionate impact of HIV/AIDS in Oklahoma. (Oklahoma Epidemiologic Profile,2008).
The level of Unmet Need, or the percent of PLWHA not in care that know that they are HIV-positive, is highest for African Americans, Hispanics, Youth and Rural residents per a study conducted in 2008 by the Oklahoma State Department of Health. The Statewide level of unmet need is approximately 48% for 2007 (Oklahoma Unmet Need Study, 2008). The OHPC reviews these reports and other sources of information (such as needs assessments and information from the community), and issues directives aimed at eliminating health disparities. Ensuring urban and rural parity in access to core medical and support services and the co-location and high level collaboration between providers to jointly manage PLWHA’s HIV disease management and other co-morbidities facilitates successful engagement and retention in care for all the underserved populations in Oklahoma.
Implementing best practice strategies which result in more ‘youth-friendly’, women-friendly’ and ‘minority-friendly’ care environments encourages entry into and retention in care. The measures of the efficacy of this HRSA strategy include the increasing number/percentage of the urban and rural underserved populations who are entering into and receiving care, combined with steady reductions in the level of unmet need, especially among the special populations.
Goal 3: Improve the Quality of Health Care
Higher-quality core medical care and support services are more effective at interrupting the progression of HIV disease and in preventing/reducing complications of the disease while contributing to quality of life and reducing the further spread of the disease. The Continuous Quality Management Program will monitor provider performance against PHS standards of care and provide training and technical assistance to all Part B providers as needed.
The OHPC in 2009 will review the quality improvement service category reports, and consider consumer needs and category performance and history as well as other funding streams available to a category when making allocation and reprogramming decisions. The measure of the efficacy of this HRSA strategy is evidenced by: 1) the integration of quality management processes and standards of care for all Part B funded services; 2) the increasingly knowledgeable and informed Part B providers and Consumers who are involved in continuous quality improvement activities; 3) compliance with public health standards; and 3) continuous performance improvements in key health indicators annually.
Goal 4: Assure Cost Effectiveness
The expenditure of Part B funds must occur after all other resources are exhausted and must assure the maximum possible impact for each dollar expended. The OHPC and its committees review expenditure and service delivery reports to assess trends in utilization of funds, services Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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provided, and costs per service category/units of service. OSDH provides expenditure and service reports to the OHPC regularly throughout the year. Where funds in a service category are under-expended, the OSDH re-programs the under-spent funds to other categories that have demonstrated need.
The Oklahoma HIV Planning Council collaborates with other funding streams to assess any duplication of services, and strives to reduce/prevent unnecessary duplication in funding streams. The measures of cost effectiveness include: 1) a PSRA process which documents use of Part B funds to fill service area gaps; 2) demonstrated maximal use of other funding streams to support the continuum of care while achieving reductions in costs per service category uses; and 3) a system of care that continues to expand access to meet the increasing demand, evidenced by a continuously expanding Part B client population in care.
Goal 5: Improve Health Outcomes
This goal sums up the overall effectiveness of both the Ryan White Part B program, and the effectiveness of all partners who serve HIV-positive consumers in the Oklahoma planning area. Outcomes for the specific service categories are interim measures of effectiveness. Outcome measures selected for measurement and reporting in the upcoming fiscal year include numerous indicators of importance to the men, women and youth to be served, including the number/percent of PLWHA with CD4 cell counts below 200 who are appropriately prescribed PCP prophylaxis and the number/percent of PLWHA on ART who achieve and maintain an undetectable viral load during the project year. Other outcome measures include the increasing number/percent of female PLWHA who receive annual Pap smears and pelvic exams and appropriate referrals; the increasing number/percent of PLWHA who receive TB testing each year, and are appropriately treated for latent and active Tuberculosis; and the decreasing number/percent of the client population that develop an AIDS diagnosis during the project year.
The ultimate health outcome measures include a reduction in emergency room and hospitalization rates and increasing survival rates/reduction in death rates due to AIDS. Improvements in quality of life outcomes to be tracked and reported include reported increases in overall health and reports of increased employment among HDAP clients.
These goals form the basis for the triennial comprehensive plan, with emphasis on the following four core themes:
1) Reduced Unmet Need, effectively moving the out of care into HIV primary medical care;
2) Increased access to care, especially among the emerging and special populations;
3) Reduced disparities in health care access and outcomes for the emerging and historically underserved populations; and
4) Continuous quality improvement, including its direct relationship to client level data and provider performance data, and positive impact on health outcomes.
Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
99
CHAPTER 13: Goals, Objectives, and Activities
This chapter identifies the Oklahoma Part B goals, and the plans to accomplish those goals during the 2009-2011 time frame, through specially developed strategies and action steps that are responsive to the state’s current situation and statewide assessment of needs, in order to meet the measurable objectives of the stated plan. This plan was developed in keeping with the HRSA guidance at the forefront, and will provide guidance to the OHPC over the next three years. The implementation plan orchestrates numerous strategies and implements new and continuing initiatives, based upon the considered needs of Oklahoma PLWHA in achieving the ideal continuum of care. All of the proposed activities include consideration of cost effectiveness and quality, so that the health outcomes of those served may continue to evidence the desired improvements.
2009 HRSA Expectations for Comprehensive Plan
Table 40. 2009 HRSA COMPREHENSIVE PLAN EXPECTATIONS
1. Ensure the availability and quality of all core medical services within the service area.
2. Eliminate disparities in access to core medical services and support services for individuals with HIV among disproportionately affected sub-populations and historically underserved communities.
3. Specify strategies for identifying individuals who know their HIV status but, are not in care, informing them about available treatment and services, and assisting them in the use of those services.
4. Include a discussion of clinical quality measures.
5. Include strategies that address the primary health care and treatment needs of those who know their HIV status and are not in care, as well as the needs of those currently in the HIV/AIDS care system.
6. Provide goals, objectives, timelines and appropriate allocation of funds (as determined by the needs assessment).
7. Include strategies to coordinate the provision of services programs for HIV prevention, including outreach and early intervention services.
8. Include strategies for the prevention and treatment of substance abuse.
Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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Short Term Goals and Long Term Goals of the 2009-2011 Oklahoma Part B Comprehensive Plan
a. Chart of Short Term Goals, Objectives, Timelines and Responsible Parties
The OHPC, in collaboration with OSDH, has identified the following 6 goals, 14 objectives and 44 activities as its action plan aimed at developing the ideal continuum of care in Oklahoma.
1
Goal # 1: Improve Access to Health Care Services
Objective 1.1: Increase access to care by 10% annually for PLWHA populations by creating more capacity for navigating and understanding care systems and other resources for services. (Baseline: 2008 New & Returning Part B Clients=1,795: Target 180 New Part B Clients with 36 new AA; 15 new Hispanic; 19 new Youth; 33 new Female; 29 new Rural and 32 new IDU clients)
Timeframe
Responsible Person(s)
Activity #1.1.1.Create and widely disseminate an updated PLWHA Resource Guide to all points of entry, including C/T, outreach, primary medical and specialty providers & other key providers & locations.
Q 1-2, Update Annually
OHPC & Committees
Activity #1.1.2. Develop referral protocols and improve communication between HIV CTR, case management, and medical staff to ensure referrals/ follow-ups are provided to newly positive clients.
Q 1, 2, 3 ,4
OSDH
Activity #1.1.3. Encourage RW Part B/C PMC, CM & MH/SA providers to implement ‘opt out’ HIV testing as an element of routine care.
Quarterly/
Annually
OSDH
Activity #1.1.4. Explore evidence-based interventions, support proposals and pilot innovative alternative models for engaging SNG clients in care.
Bi-Annually
OSDH
Objective #1.2: Reduce lag time from testing to care by 5% annually to speed entry into care for all newly diagnosed PLWHA populations and especially SNGs (Establish Baseline: 2008 Delays in Months from Testing to Care, by special population, through cross-match of PEMS and CAREWare data bases)
Timeframe
Responsible Person(s)
Activity #1.2.1.Confirm ‘Points of Entry’ & Strengthen Testing/Counseling & Referrals to Care linkages; ensure follow-up tracking strategies for referral confirmation.
Q 1-2
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Activity #1.2.2. Perform ‘Late to Care’ study as part of comprehensive 2009 In Care Needs Assessment; evaluate results and implement strategies to reduce identified barriers to care.
Q 1-4
OSDH
OHPC
Activity #1.2.3.Explore best practice peer advocacy/support models to facilitate earlier care entry & enhance care engagement among underserved populations.
Q 1-2
OHPC
Activity #1.2.4.Explore various client-centered models of care, & best practices, with emphasis on increasing ‘women’, ‘youth- ’ and ‘minority-friendly’ care environments.
Q 1-2
OHPC
Activity #1.2.5.Srengthen coordinated linkages with non- RW providers across the life span to facilitate mutual referrals and increased cross-collaborations, including IHS.
Q 2-3
OSDH
Activity #1.2.6. Explore barriers to obtaining dental care services, and implement solutions to address access issues.
Q 2-3
OSDH
OHPC
2
Goal # 2: Reduce Health Care Disparities
Objective #2.1: Reduce Level of Unmet Need by at least 2.5% Annually. (Baseline: 2008 Unmet Need=48%or 2,722: Target 90 OOC annually for total of 270 or 10% reduction in unmet need over next three years)
Timeframe
Responsible Person(s)
Activity #2.1.1. Complete an Unmet Study surveying the Out of Care populations.
Q 1-2
OSDH
OHPC
Activity #2.1.2. Address OOC Service Gaps & Barriers.
Q 3-4
OSDH
OHPC
Activity #2.1.3. Develop and implement target messages to overcome SNG barriers to care entry, and particularly for AA MSM.
Q 3-4
OHPC
Activity #2.1.4. Require bi-annual provider assessments of those who are out of HIV primary care and require providers to contact them and facilitate re-entry into care.
Q 2-4
OSDH
Activity #2.1.5. Increase utilization of peer mentors to strengthen access, engagement & retention in care among SNGs.
Q 2-4
OSDH
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Activity#2.1.6. Continually assess demographic profile of Part B clients to assure that disproportionately affected subpopulations and historically underserved communities are accessing core medical services.
Quarterly,
Ongoing
OSDH
OHPC
Objective #2.2: Evaluate Barriers to MH/SA Services and Address HIV Disease and Co-Morbidity Management among New and Returning Part B clients.(Baseline: Part B Clients assessed as needing MH/SA services compared with # of confirmed referrals)
Timeframe
Responsible Person(s)
Activity #2.2.1. Identify and implement best practice CM & PMC models to overcome the barriers to MH/SA services and improved protocols to retain mentally ill clients in care.
Q 1-2
OSDH
OHPC
Activity #2.2.2. Provide CM trainings directed toward increasing skills in accurately assessing, screening and appropriately referring clients for needed MH/SA services.
Q 2-3
OSDH
Activity #2.2.3. Identify and engage potential partners for the provision of expanded oral health, transportation, and in-patient and out-patient MH/SA treatment services.
Q 2-3
OHPC
Objective #2.3: Ensure parity of urban/rural service delivery, including assurance of access to services by non-MSA and rural residents.
Timeframe
Responsible Person(s)
Activity # 2.3.1 Ensure access to core medical and key support services for rural residents through increased coordination of RW and non-RW service providers, including IHS and 330b referrals and collaboration.
Q 2-3
OSDH
Activity #2.3.2 Explore all available transportation resources; explore innovative approaches to transportation assistance and provide resource information/education to clients and providers, to ensure enhanced access to care.
Q 2-3
OSDH
OHPC
Objective#2.4 Increase by 5% annually the number of Part B Clients retained in Primary Medical Care
(Baseline: Proportion of 2007 Part B Clients retained in care in 2008)
Timeframe
Responsible Person(s)
Activity#2.4.1 Assess cultural competency technical assistance and training needs of Part B providers and deliver TA to increase capacity to effectively serve/retain in care the disproportionately affected populations.
Ongoing
OSDH
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Activity 2.4.2. Engage AETC in the provision of CM and PMC provider trainings on resources available and increasing mutual referrals and collaborations with RW & non-RW providers and systems of care.
Q 2-4
OSDH
OHPC
Activity 2.4.3. Explore and implement evidence-based interventions directed toward Severe Need Groups to facilitate initiation and retention in medical care (prevention case management, outreach case management, interventions specific to African American MSM).
Ongoing
OSDH
OHPC
Objective #2.5 Reduce the further spread of HIV infection through enhanced primary & secondary prevention efforts in case management and primary care settings.
Timeframe
Responsible Person(s)
Activity #2.5.1. Assess the TA needs of providers and ensure each has the skills and resources to integrate effective and continuous sexual and drug use risk assessments and risk reduction counseling services for PLWHA clients and their sex and drug using partners.
Ongoing
OSDH
OHPC
Activity #2.5.2. Incorporate more education and prevention messages into the medical treatment of those living with HIV/AIDS.
Annually
OSDH
OHPC
Activity #2.5.3 Develop an action plan for ensuring clients have greater access to needs assessments.
Ongoing
OSDH
OHPC
Activity#2.5.4 Ensure ‘Voice of the Consumer’ in OHPC representation and inclusion in program planning and evaluation activities.
Ongoing
OHPC
Committees
3
Goal # 3: Improve the Quality of Services
Objective #3.1: Implement 2009 Quality Management Plan inclusive of al indicated Provider and Consumer CQI Trainings by December 2009
Timeframe
Responsible Person(s)
Activity #3.1.1. Implement and evaluate the comprehensive QM Plan and results for all Part B services.
Q 1,2, 3, 4
OSDH
OHPC
Objective #3.2:Strengthen Medical Case and Non-Medical Management Care and Systems
Timeframe
Responsible Person(s) Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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Activity #3.2.1.Conduct quality improvement trainings with Part B providers and consumers, complete performance audits of all CM providers, and implement CQI TA activities to address performance improvement issues.
Q 1,2,3,4
OSDH
Objective #3.3:Ensure Adequate Levels of Medical & Non- Medical Case Management Services to Support Access to & retention in Care
Timeframe
Responsible Person(s)
Activity #3.3.1.Conduct assessment of CM provider capacity and capability and use findings to inform system improvements.
Q 2-3
OSDH
Objective #3.4:Implement and Evaluate System-wide Client Level Data Reporting
Timeframe
Responsible Person(s)
Activity #3.4.1.Implement the system-wide strategy to collect, track and report HRSA client level data.
Q 1-4
OSDH
Activity #3.4.2.Analyze piloted results, refine strategies and evaluate first year client level data collection and reporting efforts for ways to continue to improve the process.
Q-2-4
OSDH
4
Goal #4 : Ensure Cost Effectiveness of Service Delivery
Objective #4.1:Ensure Effective Utilization of Part B Funds to fill Service Gaps and Reduce Disparities in Care
Timeframe
Responsible Person(s)
Activity #4.1.1.Compile and assess all services funding streams and encourage funds diversification to maximize utilization of Part B funds and optimize the further expansion of the Oklahoma continuum of care.
Annually
OSDH
OHPC
Activity #4.1.2.Evaluate core and support funding splits and evaluate unit costs for services across providers and service categories, to inform cost effectiveness considerations, and ensure the most appropriate expenditure of Part B funds.
Annually
OSDH
OHPC
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Activity #4.1.3.Provide ongoing 3rd party reimbursement resource acquisition and benefits trainings to all CM providers to ensure maximal use of all other available resources.
Ongoing
OSDH
Activity #4.1.4.Review service utilization data to ensure appropriate allocation of funds and expenditure of funds with no carry-over.
Quarterly
OSDH
OHPC
Activity #4.1.5. Perform annual priority setting/resource allocation process based on multiple programmatic and fiscal data sets.
Annually
Care Committee
5
Goal # 5: Improve Health Outcomes
Objective #5.1:Increase by 10% annually Part B achievement of improvements in key health outcome indicators, as evidenced by individual level client data and aggregate provider data (Baseline: 2007/2008 QM Results)
Timeframe
Responsible Person(s)
Activity #5.1.1. Evaluate effectiveness of 2009 priority CQI activities (directed toward PCP prophylaxis, Oral health visits and CM visit documentation improvements) and their impact on clinical performance measures & health outcomes.
Quarterly
Annually
OSDH
Activity #5.1.2. Implement key CQI projects to address low scoring performance measures.
Q 3-4
OSDH
Activity #5.1.3. Develop systems to track and report health outcome improvements including 1) reduced deaths due to AIDS/increased survival rates; 2) increases in quality of life as measured by increases in HDAP clients reports of improved health and return to employment.
Q 2-4
OSDH
Activity #5.1.4.Utilize the CAREWare system to generate client level health outcome indicator reports, disseminate findings, and use data to inform system improvements.
Bi-annually
OSDH
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6
Goal #6: GOAL: To Improve the Service Delivery System in the State
Objective 6.1: Ensure the planning process has wide community participation and is consumer driven
Timeframe
Responsible Person(s)
Activity 6.1.1. Conduct a full In Care/Out of Care/Late to Care needs assessment triennially (‘Voice of the Consumer’) with special studies in between.
Q1 2009, 2010 & 2011
OHPC
Activity 6.1.2. Ensure the OHPC is reflective of the epidemic and develop strategies to receive regular and in-depth input from consumer-based and regional community-based groups.
Q2, 2009
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LONG-TERM GOALS AND OBJECTIVES (Over 3-year period: FY 2009 – 2011)
STRATEGIES/ACTIVITIES
Timetable
Responsible
I. INCREASE ACCESS TO CARE
FY
’09
FY
’10
FY
’11
A. Increase Access to Care by 10% Annually Among All Population (N=180) and 10% each of Special Populations/SNGs (Baseline: 2008 Part B Clients)
Conduct community-wide services and funding Inventory & Develop/Distribute Consumer Resource Guide
􀂄
Grantee
Strengthen outreach & HIV testing/counseling and early intervention services & referral linkages in urban/rural venues targeting high risk & aware/not in care
􀂄
􀂄
Grantee
Council
Grantee
Encourage & support PMC , CM & other core medical providers to implement ‘opt out’ HIV testing
􀂄
􀂄
Grantee
Explore and Support Proposals/pilot innovative strategies to increase client engagement in care/Increase use of Peer mentors
􀂄
􀂄
􀂄
B. Encourage earlier Care Entry & Reduce Lag Time from Testing to Care by 5% Annually for all Newly Diagnosed PLWHA
Confirm ‘points of entry’ and strengthen Testing/Counseling to Care linkages
􀂄
􀂄
Grantee
Council
Explore best practices and pilot innovative models of care that encourage earlier entry and retention in care for youth, men, women and minorities, and particularly AA MSM.
􀂄
􀂄
Council
Strengthen coordinated linkages with non-RW providers of services across the lifespan to increase mutual referrals and care sources
􀂄
􀂄
􀂄
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STRATEGIES/ACTIVITIES
Timetable
Responsible
II.REDUCE HEALTH CARE DISPARITIES
FY
’09
FY
’10
FY
’11
A. Reduce Level of Unmet Need by at least 2.5% Annually
Council
Conduct ‘Out of Care’ study, analyze findings and use priority setting process to implement changes in Service Delivery System
􀂄
􀂄
Continuously assess demographic profile of Part B clients to assure that disproportionately impacted and historically underserved are accessing services
􀂄
􀂄
􀂄
Grantee
Council
B. Evaluate Barriers and Address HIV Disease and Co-Morbidity Management among New and Returning Clients
Conduct study of barriers to usage of existing MH/SA services and explore best MCM/CM & PMC practices to jointly address MH and SA needs among Part B clients
􀂄
􀂄
Council
􀂄
􀂄
􀂄
Grantee
Identify and engage state & CBO partners for the provision of expanded transportation, oral health, and outpatient and inpatient MH & SA services
Council
C. Ensure Parity of Urban/Rural Service Delivery, including Assurance of Transportation/Oral Health services for Urban and Rural Residents
Increase collaboration and coordination of RW and non-RW providers, and expand transportation assistance to create more parity between urban/rural care resources
􀂄
􀂄
􀂄
Council
D. Increase by 5% Annually the number of Part B Clients Retained in Primary Medical Care
Refine coordination & linkage of Outreach, Case Management and Primary Medical Care
􀂄
􀂄
􀂄
Grantee
Council
Evaluate and implement numerous strategies to positively impact PLWHA retention in care
􀂄
􀂄
􀂄
Grantee Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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STRATEGIES/ACTIVITIES
Timetable
Responsible
E. Reduce the Further Spread of HIV Disease through Enhanced Primary & Secondary Prevention Linkages and Programs
FY
’09
FY
’10
FY
’11
Assess and address TA needs of providers to ensure competency in performing serial risk assessments and providing risk reduction education and counseling for PLWHA and their sex and drug using partners
􀂄
􀂄
􀂄
Grantee
Incorporate more education and prevention messages into the medical treatment of those living with HIV/AIDS
􀂄
􀂄
􀂄
Grantee
III. IMPROVE QUALITY OF SERVICES
A. Strengthen & Refine Medical and Non-Medical Case Management Services and Systems
Conduct CM Trainings and implement improvements
􀂄
􀂄
􀂄
Grantee
B. Implement 2009 CQI trainings and performance audits of MCM and non-medical CM providers.
Implement TA activities to address performance improvement issues
􀂄
􀂄
􀂄
Grantee
C. Ensure Adequate levels of Medical and Non-Medical Case Managers to support Access and Retention in Care
Conduct assessment of CM provider capacity and use findings to inform the system changes/improvements
􀂄
􀂄
􀂄
Grantee
Council
D. Implement and Evaluate System-Wide Client Level
Data Reporting
Implement, evaluate and continuously refine client level data reporting system and provide TA and guidance as indicated.
􀂄
􀂄
􀂄
Grantee Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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STRATEGIES/ACTIVITIES
Timetable
Responsible
IV. ENSURE COST EFFECTIVE SERVICE DELIVERY
FY
’09
FY
’10
FY
’11
A. Ensure Effective Utilization of Part B Funds to fill Service Gaps and Reduce Disparities in Care
Assess all funding streams, encourage maximize utilization of Part B funds and expand continuum of care.
􀂄
􀂄
􀂄
Grantee
Council
Review funding split between core and support services
􀂄
􀂄
􀂄
Council
Analyze accessibility/quality/utilization of core services in service delivery system
􀂄
􀂄
􀂄
Council
Conduct priority setting/resource allocation process
􀂄
􀂄
􀂄
Council
V. IMPROVE HEALTH OUTCOMES
A. Increase by 10% Annually in Part B Provider Improvements in Key Health Outcome Indicators, as Evidenced by Client Level Data Sets
Review/Refine Standards of care for Part B funded Case Management services, perform chart audits, compare findings to HRSA performance expectations, and implement corrective plans
􀂄
􀂄
􀂄
Grantee
Utilize CAREWare system to generate client level health outcomes indicator data, disseminate findings, and use the data to inform system improvements
􀂄
􀂄
􀂄
Grantee
Ensure OHPC is consumer-driven and reflective of epidemic Ensure widespread consumer and provider input
􀂄
􀂄
􀂄
Grantee
Council
Utilize multiple sources of data for evaluation and planning
􀂄
􀂄
􀂄
Grantee
Council
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STRATEGIES/ACTIVITIES
Timetable
Responsible
VI. IMPROVE SERVICE DELIVETY
FY
’09
FY
’10
FY
’11
A. Ensure the planning process has wide community participation and is consumer driven
Assure mechanism to involve Part B Clients in Needs Assessment Activities
􀂄
􀂄
􀂄
Grantee
Council
Conduct a full needs assessment triennially (‘Voice of the Consumer’) with special studies in between
􀂄
􀂄
􀂄
Grantee
Council
Ensure the OHPC is reflective of the epidemic and develop strategies to receive regular and in-depth input from consumer-based and regional community-based groups.
􀂄
􀂄
􀂄
Grantee
Council
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SECTION IV. How will we monitor our progress?
Introduction to Section IV: Multiple persons and many agencies have a role in implementing the goals of the 2009-2011 SCSN and Oklahoma Comprehensive Plan. The primary responsibility for ensuring that the plan is implemented, and for monitoring its implementation, falls to the OHPC’s Care Committee, in collaboration with the Oklahoma State Department of Health. However, the planning and implementation of the three-year plan requires the full cooperative effort of all Ryan White and other planning and provider partners across the state.
CHAPTER 14: Implementation, Monitoring and Evaluation Plan
Implementation Processes
The Oklahoma HIV Planning Council (OHPC) uses several processes to accomplish the various strategies identified in the action plan. These processes are identified below.
OHPC Leadership Activities
Although the Planning Council performs most of its work through a committee structure, council leadership is responsible for spearheading collaborative activities with OSDH partners.
OHPC Committee Activities
Each OHPC committee has ongoing responsibility for one or more HRSA- and/or CDC--mandated activities. Within these mandates, committees target their activities to accomplish plan strategies.
The Executive Committee is comprised of the Community Co-Chair, OSDH Co-Chair, Two Ex-Officio members of the HIV/STD Service staff (Director of Prevention and Intervention and Director of the Division of Surveillance and Care Delivery) and the Chairs of the OHPC Committees.
• The Membership Committee focuses its council membership recruitment efforts toward engaging wide consumer involvement and the necessary talent and leadership required to fill the voting seats and encourage their full participation in council activities.
• The Assessment and Evaluation Committee monitors special needs assessment studies and reviews reports it has requested. This committee is responsible for evaluating the needs for HIV prevention and care in Oklahoma and for tracking current and future trends in HIV infection. This committee also tracks and evaluates care funded services and expenditures and reviews quality of care reports, making recommendations for improvements. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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• The Policy Committee develops and recommends policies for the operations of the OHPC, including but not limited to Conflict of Interest, Grievance, and Confidentiality policies, as well as developing various operating and other procedures.
• The Care Committee is responsible for assisting in the planning and reviewing of Ryan White funded services and assisting OSDH with the development of the Comprehensive Strategic Plan and Statewide Coordinated Statement of Need. The Care Committee’s planning processes include the analysis of multiple data sources including consumer assessments of need, service expenditures by category, service utilization and quality improvement data. The Care Committee also contributes a portion of the Comprehensive HIV Prevention Plan which pertains to accessing all available care and services.
• The Prevention Committee is responsible for the prioritization of HIV prevention target populations and a set of prevention interventions for each target population, as well as the presentation of this information to the OHPC. The committee also completes a portion of the Comprehensive Strategic Plan that addresses these items.
Provider Contracting and Contract Monitoring Process
OSDH establishes contract conditions of award and monitors Part B contract performance. Some planning council directives are included among the conditions of award, and are subsequently monitored. Monitoring is performed both by review of documents submitted by providers and by OSDH site visits to providers.
The Oklahoma Part B site-visitation process is comprehensive and occurs at least bi-annually to:
1) Review the agency’s/program’s capacity and effectiveness in delivering HIV care and services according to the Part B legislation and guidance;
2) Review the program’s effectiveness of service implementation in accordance with the goals and objectives specified in the grant application/contract;
3) Assess consumer satisfaction and level of involvement in the program;
4) Identify areas of strengths and areas of needed improvement(s) in service delivery;
5) Identify best-model practices;
6) Ensure compliance with the all Part B Standards of Care; and
7) Make recommendations for technical assistance aimed at improving the quality of care and services and continued compliance with Part B funding guidelines.
Monitoring and Evaluation
The OHPC is the body primarily responsible for the development of this plan and, in collaboration with OSDH will ensure the plan’s implementation, monitor its components and evaluate the proposed goals, objectives and strategies.
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CHAPTER 15: Improving Client Level Data
The Quality Committee is fully implementing the new client level data system collection which started in January 2009. The OSDH has been using CAREWare since 2001 to track services and client information, so providers are very accustomed to collecting and reporting client level data to OSDH. Challenges currently revolve around collecting more detailed clinical information in CAREWare from medical providers. OSDH did incorporate the performance measures into their most recent contracts with medical providers, and the Manager of Care QA and Data Analysis has been reinforcing the importance of clinical documentation in CAREWare. Missing data reports are available to providers and with providers being centralized on the main server at OSDH, the Manager of Care QA and Data Analysis can create reports and copy them to providers to run as needed to improve data quality. In addition, Performance Measures Groups 1 and 2 are available to all providers in CAREWare to perform at any time at the click of a button. The grantee provided training to all providers on the RDR and RSR systems in January and reviewed with each the required data elements and new clinical information required. The Manager of Care QA and Data Analysis (in addition to data quality staff from a large medical provider) participated in the RDR/RSR training from HRSA.
The OSDH will use CAREWare to generate an export file that can be directly uploaded to the RSR system. Currently all medical and non-medical providers use CAREWare to enter service data so uploading medical and non-medical case management provider and client data is not an issue. OSDH’s focus will be on ensuring data completeness and accuracy, especially focusing on screenings and detailed clinical information that is needed.
Currently, the OSDH has conducted baseline analysis of performance measures and has identified areas for improvement using the Performance Measures Module in CAREWare or RDR. Data is incomplete for some clinical variables so the QC will work with providers to improve the data completeness. These measures will provide evidence of performance over time and assist the grantee with identifying areas for improvement with services and quality of care. Overall, the performance measures are consistent with the client level data that needs to be uploaded to HRSA with the RSR, so monitoring the performance measures in CAREWare will assist the grantee with preparation for the RSR collection that began in January of 2009.
A QI formal meeting process has now been in place for over a year and provides a structured environment for the discussion of quality improvement issues. The Quality Committee meets monthly and minutes are recorded. In addition, the Manager of Quality Assurance and Data Analysis continues to utilize the skills gained from the Train-the-Trainer Program from the National Quality Center, and has conducted four quality improvement trainings to date. All members of the Quality Committee (QC) have been trained in PDSA, QI Theories and Principles, Performance Measurement, RW Quality Expectations, and Leadership for Quality Improvement.
Although performance measures have always been tracked, the quality management plan was primarily the responsibility of the Manager of Quality Assurance and Data Analysis and attention was more focused on measurement rather than process. With the implementation of Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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quality committee meetings, other staff have become involved in the process and are trained in quality improvement activities as well so that formal PDSA cycles and improvement projects are not the responsibility of one or two individuals. This has also created a sense of teamwork and allows staff to present concerns so that the group can process possible solutions. Based on the work and feedback from the QC, technical assistance requests for case management are efficient and providers are satisfied with the training they are receiving.
Medical case management quality improvement visits are assisting case managers with performance improvement. During 2008, each medical case management site received a report detailing areas of strength and areas for improvement in CAREWare documentation, medical case management chart documentation, preparation for the RDR and RSR, and client satisfaction. The Coordinator of Case Management Services, Director of Care Delivery, Contract Monitor, and Manager of Care QA and Data Analysis have been conducting these team visits along with CDC funded prevention quality assurance staff. The team has been a great asset to assist case managers with evaluating their services and providing recommendations for improvement. The QC also partnered with a pharmaceutical company in December of 2008 to conduct medication adherence behavioral change training for case managers and medication adherence staff. This training was a great opportunity for case managers to improve motivational interviewing skills.
Clinical quality progress reports and results of QI studies are presented to the Oklahoma HIV Planning Council’s Evaluation and Assessment Committee for review. In addition, the Manager of Quality Assurance and Data Analysis has provided quality improvement training to the OHPC on Quality Management Expectations of Ryan White Grantees and Client Satisfaction. Performance measure data has been an integral piece to the collaboration of Ryan White Parts B, C and D in Oklahoma. Since all Parts use CAREWare and data is stored centrally by the OSDH, performance measures are calculated for clients receiving Parts B through D statewide. OSDH is also currently collaborating with a Part C and D clinic to establish a Statewide “Consumers for Quality Group” that will report to the Quality Committee. Based on QM data statewide on the increasing caseloads of medical case managers, OSDH increased Part B funding to support more medical case managers at the Part C clinics in Oklahoma City and Tulsa.
Planned Quality Activities
Goals and Objectives for FY 2009
1. Goal: Improve performance measure data and clinical client data documentation in CAREWare.
• Objective: By April of 2009, provide training on performance measures, RDR reporting, and RSR data collection.
2. Goal: Improve efficiency and completeness of client level data reporting/ application process for the HIV Drug Assistance Program and Health Insurance Assistance Program. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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• Objective: By March of 2010, have online case management system in place that will include an online application process.
3. Goal: Complete data collection and analysis on quality improvement projects.
• Objective: By March of 2010, conduct quality improvement projects (dental care exams and updated care plans) using Plan, Do, Study, Act methodology and implement positive changes.
4. Goal: Implement a consumer advisory process for Part B services to assist with quality improvement activities.
• Objective: By March of 2010, conduct quality improvement training for consumers and form committee of Consumers for Quality that reports to the overall Quality Committee.
5. Goal: Improve treatment adherence outcomes of new HIV Drug Assistance Program clients.
• Objective: By March of 2010, conduct evaluation of adherence counseling and education program with clients of HIV Drug Assistance Program.
6. Goal: Update and improve current case management standards.
• Objective: By March of 2010, establish workgroup, process and timeline for revising case management standards.
7. Goal: Update and improve current provider quality management plans.
• Objective: By March of 2010, conduct at least 1 site visit per agency to review quality management plans and make recommendations for improvements.
CHAPTER 16: Using Data for Evaluation
Using Data to Improve or Change Service Delivery in the State
A comprehensive system of program data tracking and program evaluation has been developed and will continue throughout the next project period to capture and report the required administrative and clinical program data. Both formative (monthly/quarterly) and summative (biannual) evaluations will continue to be performed in compliance with the goals and objectives of the comprehensive plan. Annual budget period renewal applications, delineating progress toward the stated goals and objectives will be submitted each year, and the Data Reports will be submitted each year, according to HRSA/HAB’s requirements.
OSDH has developed a thoughtful, planned and systematic process for monitoring and evaluating the quality, comprehensiveness, accessibility and clinical outcomes of the Ryan White Part B funded service categories. Performance progress data is collected monthly according to a Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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service-specific (i.e., EIS/case finding, primary medical care, medical case management and treatment adherence, referrals, etc) management information system that, together, captures all relevant program services data on an ongoing basis. These data reports form the basis for the annual OHPC planning activities, OSDH narrative progress reports and the annual data reports.
Multiple sources of data are used to evaluate the State’s level of progress toward achievement of the five key Health Resources and Services Administration (HRSA) goals: 1) improve access to care, 2) eliminate health disparities, 3) improve the quality of care, 4) assure cost effectiveness, and 5) improve health outcomes. Examples of the types of data to be used to evaluate attainment of these goals include the following:
Improving access to care and reducing access disparities: Individual level client data will be gathered and tracked regarding testing/referral source and length of time between testing and care entry. Each provider will track and report the number of new and returning patients by demographic profile, compared to the evolving profile of the local epidemic to evaluate the level of access and whether access is increasing, especially among the underserved and hard-to-reach populations in the urban and rural portions of the state.
Needs assessment data will be analyzed for the generation and testing of new interventions and strategies to reduce the stated barriers to access and retention in care among PLWHA. Provider and PLWHA-identified service gaps will be addressed through the annual planning processes, with ongoing monitoring of the state’s level of success in reducing gaps in the core medical and key supportive services. Individual level client data and aggregate provider data by service category will be tracked and analyzed to determine the degree to which Oklahoma is reducing access disparities among each of the special populations.
Individual level client data will be tracked and evaluated for the number and proportion of PLWHA who are present and retained in primary medical care (evidenced by making and keeping at least one primary medical care visit during the initial six month time period and achieving at least one PMC visit during the second six month period of each project year) as a key measure of retention in care. Routine analyses of the Medical and non-Medical Case Manager’s initial and annual client assessments of support service needs compared to level and extent of confirmed referrals and service usage will be used to examine the extent of confirmed access to medical services and the degree to which the supportive services are contributing to PLWHA engagement with and their sustained retention in care.
Reducing level of unmet need: Individual level client data will be tracked regarding dates of previous testing, previous medical care and length of absence from care upon entry into care and upon re-entry into HIV medical care. OSDH will perform a cross-match of PEMS data to CAREWare data to evaluate length of delays from testing and entry into care. Multiple strategies are outlined to aggressively reduce the high level of unmet need in the state of Oklahoma and expand services to assure all PLWHA of access to core medical services and key supportive services to maximize utilization of services and retention in care. The OSDH will utilize data from multiple sources to evaluate progress in reducing the out of care fraction in Oklahoma. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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Ensuring cost-effectiveness of services delivery: Key data elements that are tracked and analyzed on a monthly, quarterly and annual basis include provider reports of cost expenditures by client and by service category; continual evaluation of the other local resources available; maximal use of non-Ryan White sources of care and funding to support the Oklahoma continuum of care; and analysis of individual client level data for evidence of duplicative service delivery, with actions taken to prevent or reduce any unnecessary duplication.
Improving the quality of the care and services delivered: A robust quality management system ensures the continued progress toward achieving the highest level of quality possible, according to HRSA/HAB performance measures, as discussed at length in the following chapter.
Improving the health outcomes of individual PLWHA: The plans to utilize client level data along with aggregate provider data, by service category, in order to demonstrate how Part B funded services are improving HIV-related clinical health outcomes, are comprehensively discussed in the following chapter.
CHAPTER 17: Clinical Quality Management
CQM Program Structure
Purpose, Vision, Mission
The purpose of the Quality Management (QM) Program is to set forth a coordinated approach to ensuring Part B clients have access to high quality services that are consistent with Public Health Service Guidelines for the treatment of HIV/AIDS. The mission of the QM Program is to improve the quality and availability of health care and support services to eligible individuals and families living with HIV disease. Quality Improvement (QI) principles will be utilized as a basis for improvement of care and services. The QM Program strives to continuously improve the quality of care and services in a multidisciplinary team approach and are consistent with the overall commitment to quality within the Oklahoma State Department of Health and HIV/STI Service.
Overall Goals and Objectives
A systematic, program-wide process for planning, designing, measuring, assessing and improving performance will include the following components:
A. Develop a planning mechanism incorporating baseline data from external and internal sources (list data sources) and input from department leadership, staff and clients. Clinical, operational and programmatic aspects of client care will be reviewed.
B. Emphasize design needs associated with new and existing services, patient care delivery, work flows and support systems which maximize results and satisfaction on the part of the clients and their families, providers and staff. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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C. Evolve and refine measurement systems for identifying trends in care and sentinel events by regularly collecting and recording data and observations relating to the provision of client care across the continuum.
D. Employ assessment procedures to determine efficacy and appropriateness and to judge how well services are delivered and whether opportunities for improvement exist.
E. Focus on improving quality in all of its dimensions by implementing multidisciplinary, data driven, project teams and encouraging participatory problem solving.
F. Promote communication, dialogue and informational exchange across the department and throughout the organizations reporting structure, with regard to findings, analyses, conclusions, recommendations, actions and evaluations pertaining to performance improvement.
G. Strive to establish collaborative relationships with diverse community and healthcare agencies for the purpose of collectively promoting the general health and welfare of the community served
FY 2008 Part B funds allocated to clinical quality management
Oklahoma allocated 3.5% of its FY08 Part B funds to quality management.
QM Program Roles and Responsibilities
The department’s leadership group, Director of Care Delivery, Contract Monitor, Manager of HIV Drug Assistance, Health Insurance Assistance, and Home Health Programs, Coordinator of Health Insurance Assistance, Manager of Quality Assurance and Data Analysis, Coordinator of Case Management Services, and HDAP Enrollment Coordinator, is accountable, responsible and answerable for planning, directing, coordinating and improving healthcare services in the Ryan White Part B Program. This leadership group approves the performance improvement plan, and reviews quality improvement activities during its regular meetings.
The leadership group has formed a Quality Committee (QC), under the direction of the Director of Care Delivery. The QC, Director of Care Delivery, and HIV/STI Service Chief oversee the allocation of resources to quality management activities. The Manager of Quality Assurance and Data Analysis serves as the QC leader and coordinates the QC activities and agenda topics, including establishing the quality management program and coordinating the QI plan and improvement projects. The Director of Care Delivery serves as the QC facilitator, providing support and feedback to the QC leader. QC member responsibilities include suggesting problem-solving tools, offering ideas and active participation in improvement projects, respecting meeting ground rules, reviewing QI plan goals and indicators, regular meeting attendance, and rotating meeting minute responsibilities.
Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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The Oklahoma HIV Planning Council (OHPC) members (providers and consumers) provide ongoing quality improvement feedback through the Evaluation and Assessment Committee. The Manager of Quality Assurance and Data Analysis reports quality activities to this committee and provides quality training to OHPC members, QC members, and contracted providers. In addition, the Manager of Quality Assurance and Data Analysis reports member recommendations and concerns to the QC. Through the Division of Care Delivery, the QC also provides ongoing QI reports to the HIV/STD Service Chief and HIV community and medical providers.
Process for Evaluation of QM Program and Activities
Once an opportunity for improvement has been identified, a multidisciplinary improvement project team will be convened to analyze the process and develop improvement plans. These teams will include those staff members closely associated with the process under study. Every attempt will be made to include individuals from other areas who may be impacted by changes made by the team and to help promote collaboration between agencies.
Continuous Quality Improvement Methodology will be utilized and will include but not be limited to the following:
• PDSA (Plan/Do/Study/Act) • Flow Chart Analysis • Cause-and-Effect
Diagrams • Brainstorming • Observational Studies/patient flow • Activity Logs
Quality Committee/Team Meeting Record Improvement Plans will be developed and implemented by the teams. Improvements may include:
• System Redesign • Education or Technical Assistance (Internal or Provider Staff/Patients) • Clinical Guidelines review, revision or development• Procedure and policy changes • Form development or revision
All improvement plans will be communicated to all staff and to providers/ clients if deemed appropriate. Meetings, e-mails, memos, and informal verbal communications are all considered appropriate methods to communicate the team’s activities and improvement plans, as long as all parties are included in the process.
Specific Indicators Being Monitored for Core Medical Services and Data Collection Strategy
The QC will be monitoring core medical services in accordance with the HAB performance measures for core medical, Groups 1, 2, and 3. Once approved Group 3 (in draft form) performance indicators (HDAP, Case Management, and Dental) will be measured as well. OSDH also measures indicators associated with satisfaction and health status. Indicators will be analyzed using data from Ryan White CAREWare, EMR, the new Ryan White Services Report, HDAP/HIAP enrollment database, medical case management chart reviews, and client satisfaction surveys.
The QC will monitor progress toward indicators by reviewing data quarterly. The QC has established baselines for the core medical performance measures deemed critical by HAB Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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(Group 1). Complete data for 2007 was not available in CAREWare for PCP prophylaxis, and will be a measure the QC and medical providers will work toward standardizing for data collection procedures as an improvement project.
Performance indicators include the following for 2009. Baseline data is included with dates of reporting period and data source.
Table 41: 2009 Performance Indicators
Indicator
Baseline Percentage
Reporting Period
Data Source
Percentage of clients with HIV infection who had two or more CD4 t‐cell counts performed in the measurement year.
73%
1/1/2007 thru 12/31/2007
CAREWare
Percentage of clients with AIDS who are prescribed HAART.
100%
1/1/2007 thru 12/31/2007
RDR, CAREWare
Percentage of clients with HIV infection who had two or more medical visits in an HIV care setting in the measurement year.
86%
1/1/2007 thru 12/31/2007
RDR, CAREWare
Percentage of clients with HIV infection and a CD4 T‐cell count below 200 cells/mm3 that were prescribed PCP prophylaxis.
Insufficient Data
1/1/2007 thru 12/31/2007
CAREWare
Percentage of pregnant women with HIV infection who are prescribed antiretroviral therapy.
95%
1/1/2007 thru 12/31/2007
RDR, CAREWare
Percentage of women with HIV infection who have a Pap screening in the measurement year.
77%
1/1/2007 thru 12/31/2007
RDR, CAREWare
Percentage of clients with HIV infection for whom Hepatitis C (HCV) screening was performed at least once since the diagnosis of HIV infection.
18%
1/1/2007 thru 12/31/2007
RDR, CAREWare
Percentage of clients with HIV infection who received an oral exam by a dentist at least once during the measurement year.
38%
1/1/2007 thru 12/31/2007
CAREWare
Percentage of adult clients with HIV infection who had a test for syphilis performed in the measurement year.
60%
1/1/2007 thru 12/31/2007
RDR, CAREWare
Percentage of clients with HIV infection who received testing with results documented for latent tuberculosis infection since HIV diagnosis.
52%
1/1/2007 thru 12/31/2007
RDR, CAREWare Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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Indicator
Baseline Percentage
Reporting Period
Data Source
Percentage of HIV positive clients satisfied with Ryan White medical case management services in the measurement year.
89%
1/1/2008 thru 12/31/2008
Case Management Client Satisfaction Survey
Percentage of HIV‐infected medical case management clients who had a medical case management care plan documented and updated two or more times in the year.
71%
1/1/2008 thru 12/31/2008
Medical Case Management Chart Review
Percentage of HIV‐infected medical case management clients who had 2 or more medical visits in an HIV care setting in the measurement year.
49%
1/1/2007 thru 12/31/2007
CAREWare
Percentage of HDAP applications approved or denied for HDAP enrollment within 2 weeks of HDAP receiving a complete application.
99%
4/1/2007 thru 3/31/2008
HDAP/HIAP enrollment/ chart review
Percentage of clients enrolled in HDAP or Health Insurance Assistance that rate their health as good or very good in the measurement year.
68%
4/1/2007 thru 3/31/2008
HDAP/HIAP enrollment
Percentage of HDAP or Health Insurance Assistance clients stating their health had improved after being on ART for a year or more in the measurement year.
76%
4/1/2007 thru 3/31/2008
HDAP/HIAP enrollment
Percentage of HDAP or Health Insurance Assistance clients that had undetectable viral loads in the measurement year.
73%
4/1/2007 thru 3/31/2008
HDAP/HIAP enrollment
✓Annual Quality Goals
Based on last year’s performance rates, the quality committee prioritizes the following 2009 quality projects. Quality improvement project teams will be initiated in order to improve the following:
1. Percentage of clients with HIV infection and a CD4 T-cell count below 200 cells/mm3 prescribed PCP prophylaxis. Data entry issue in CAREWare. Goal is 90%.
2. Percentage of clients with HIV infection who received an oral exam by a dentist at least once during the measurement year. Possible data entry issue. Goal is 50%.
Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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3. Percentage of HIV-infected medical case management clients who had a medical case management care plan documented and updated two or more times in the measurement year. Documentation issue in case management charts. Also need to record in CAREWare for RSR. Goal is 80%.
✓ Regular review of data for performance measures from a variety of sources will occur quarterly. The Manager of Quality Assurance and Data Analysis will coordinate these activities. Data reports will be presented for review to Quality Committee and designated teams. Data sources will include but will not be limited to:
• Clinical Measures utilizing RW CAREWare
• Client Satisfaction Survey results
• Demographic data, visit frequency, referral data from CAREWare
• Drug utilization pattern, adherence, and pharmacy data from OU College of Pharmacy system.
• Quality of Life data from HIV Drug Assistance Program and Health Insurance Assistance Program enrollment data.
• Chart Audit data from case management and mental health.
Data collection will be implemented utilizing appropriate sampling methodology and will include both concurrent and retrospective review.
Assessment and Evaluation
Assessment and evaluation of the data will be performed by various existing teams (Contracts and Administration, HDAP/HIAP, Quality Assurance and Data Analysis, Senior Management, OHPC Assessment and Evaluation Committee) who will determine if the data warrants further evaluation. Based on this ongoing review, priorities will be set and opportunities for improvement identified.
Multidisciplinary Team and Development of Improvement Plan
Once an opportunity for improvement has been identified a multidisciplinary team will be convened to analyze the process and develop improvement plans. These teams will include those staff members closely associated with the process under study. Every attempt will be made to include individuals from other areas who may be impacted by changes made by the team and to help promote collaboration between agencies.
Continuous Quality Improvement Methodology will be utilized and will include but not be limited to the following:
• PDSA (Plan/Do/Study/Act) Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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• Flow Chart Analysis
• Cause-and-Effect Diagrams
• Brainstorming
• Observational Studies/patient flow
• Activity Logs
Quality Committee/Team Meeting Record Improvement Plans will be developed and implemented by the teams. Improvements may include: • System Redesign• Education (Staff/Patients) • Clinical Guidelines review, revision or development• Procedure and policy changes• Form development or revision
All improvement plans will be communicated to all staff and to providers/ clients if deemed appropriate. Regular meetings, e-mail, memos, and informal verbal communication are all considered appropriate methods to communicate the team’s activities and improvement plans, as long as all parties are included in the process.
F. Sustaining Improvements
Regular feedback regarding improvement projects is critical to its success in sustaining improvements over time. Once an improvement plan has been successful a regular monitoring schedule will be implemented to determine whether the plan remains successful over time.
Description of HDAP Quality Management Program
Improvements and changes needed in program service delivery can be determined based on review of data. The Advisory Committee’s primary purpose is to make HDAP formulary recommendations and uses guidelines for formulary changes. These guidelines include a review of clinical information, cost consideration of the drug, and program budget implications. The grantee takes into consideration the cost neutrality of the drug as compared to other drugs already in the existing class of drugs and data, if available, to project program utilization and cost. This committee consists of Infectious Disease physicians, HIV specialists and clinical pharmacists involved in the care of HDAP patients, including physicians connected with the Part C clinics. This committee has managed effectively by meeting electronically and by conference call on an as needed basis. If further communication is needed, meetings can be scheduled. This process has helped to expedite the addition of new FDA approved antiretroviral drugs to the program formulary.
The grantee is linked with AETC who provides workshops for Ryan White providers including HDAP prescribing physicians. The information presented in these workshops is continually updated with the latest guidelines. Members of the Advisory Committee are also part of the AETC as consulting physicians for health care practitioners statewide. The HDAP manager also presents jointly with AETC staff to health care providers on HDAP.Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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APPENDICES
Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
126
AIDS Incidence
AIDS Prevalence
HIV (not aids) Prevalence
01/01/06 to 12/31/07
as of 12/31/07
as of 12/31/07
Demographic Group/Exposure Category
AIDS incidence is defined as the number of new AIDS cases diagnosed during the period specified.
AIDS Prevalence is defined as the number of people living with AIDS as of the date specified.
HIV Prevalence is defined as the estimated number of diagnosed people living with HIV (not AIDS) as of the date specified.
Race/Ethnicity
Number
% of Total
Number
% of Total
Number
% of Total
White, not Hispanic
229
51.3
1,532
47.9
1,137
40.5
Black, not Hispanic
116
26.0
462
14.5
430
15.3
Hispanic
47
10.5
122
3.8
96
3.4
Asian/Pacific Islander
3
0.7
0
0.0
2
0.1
American Indian/Alaska
32
7.2
151
4.7
99
3.5
Multi- Race
19
4.3
0
0.0
0
0.0
Unknown
0
0.0
928
29.0
1,046
37.2
Total
446
100.0
3,195
100.0
2,810
100.0
Gender
#
% of Total
#
% of Total
#
% of Total
Male
370
83.0
2,738
85.7
2,273
80.9
Female
76
17.0
457
14.3
537
19.1
Total
446
100.0
3,195
100.0
2,810
100.0
Age at Diagnosis (Years)
#
% of Total
#
% of Total
#
% of Total
<13
1
0.2
11
0.3
37
1.3
13-14
1
0.2
2
0.1
2
0.1
15-24
24
5.4
180
5.6
610
21.7
25-34
108
24.2
1,120
35.1
1,125
40.0
35-44
177
39.7
1,302
40.8
733
26.1
45-54
109
24.4
474
14.8
246
8.8
55-64
20
4.5
92
2.9
48
1.7
>=65
6
1.3
14
0.4
9
0.3
Total
446
100.0
3,195
100.0
2,810
100.0 Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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AIDS Incidence:
AIDS Prevalence
HIV (not aids) Prevalence
01/01/06 to 12/31/07
as of 12/31/07
as of 12/31/07
Demographic Group/
Exposure Category
AIDS incidence is defined as the number of new AIDS cases diagnosed during the period specified.
AIDS Prevalence is defined as the number of people living with AIDS as of the date specified.
HIV Prevalence is defined as the estimated number of diagnosed people living with HIV (not AIDS) as of the date specified.
Adult/Adolescent AIDS Exposure Category
Number
%
Number
%
Number
%
Male‐to‐male sexual contact
197
44
1,674
53
1,345
49
Injection drug use
57
13
384
12
330
12
Male‐to‐male sexual contact and injection drug use
40
9
412
13
250
9
Hemophilia/coagulation disorder
1
0
14
0
7
0
Heterosexual contact
58
13
343
11
336
12
Receipt of blood, components, or tissue
2
0
22
1
20
1
Perinatal exposure, HIV diagnosed >= 13
0
0
0
0
0
0
Other risk factor reported
0
0
0
0
0
0
Risk not specified
88
0
331
10
485
17
Total
443
100
3,180
100
2,773
100
Pediatric AIDS Exposure Categories
Number
%
Number
%
Number
%
Hemophilia/coagulation disorder
0
0
1
9
4
11
Mother with/at risk for HIV infection
1
100
9
82
27
73
Receipt of blood, components, or tissue
0
0
0
0
0
0
Other risk factor reported
0
0
1
9
6
16
No identified risk factor (NIR)f
0
0
0
0%
0
0%
No risk factor reported (NRR)g
0
0
0
0
0
0
Total
1
100
11
100
37
100 Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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State of Oklahoma Implementation Plan – Oklahoma State Department of Health
Ryan White Part B ‐ FY 2009 (April 1, 2009 – March 31, 2010)
Part B Program Area: Part B Base
Total Number of Contractors/Providers Funded in FY 2009: 5
Service Goal Statement: To link eligible Persons Living With HIV/AIDS in Oklahoma to appropriate outpatient medical care and support services to improve health status.
Quantity: Provide the number of people to be served and service units to be provided during the grant year.
Objective/s: List quantifiable and time‐limited objectives relating to the Program Area named above. Where appropriate, list multiple objectives that are required to implement a new service, or to continue an existing service.
Service Unit Definition: Provide the name and definition of the unit of service to be provided (e.g. a one‐hour face‐to‐face encounter, one round‐trip bus ride).
Number of People to be Served
Total number of Service Units to be Provided
Time Frame: Indicate the estimated duration of activity relating to the objective listed.
FY 2009 Funds: Provide the approximate amount of Part B funds to be used to provide this service. Where possible, divide funding among individual objectives.
1. Identify and link to primary medical care HIV+ individuals statewide who know their HIV status but are not in care.
One face to face outreach case management visit
120
300
Apr 09 –
Mar 10
$135,000
Comanche County $45,000
Oklahoma City $45,000
Tulsa $45,000
2. Coordinate medical care through clinical case management at Part C EIS clinics utilizing an interdisciplinary medical model.
One face to face clinical case management visit
1,000
2,000
Apr 09 –
Mar 10
$390,000:
$230,000 Oklahoma City
$160,000 Tulsa
3. Coordinate medical and social support services through community case management.
One community case management face to face visit
720
1,440
Apr 09 –
Mar 10
$315,000:
$135,000 OKC MSA
$135,000 Tulsa MSA
$45,000 Comanche County
4. Provide eligible Part B clients with HIV medications not covered on the ADAP formulary.
One prescription
500
3,500
Apr 09 –
Mar 10
$304,670 statewide:
$182,802 western Oklahoma
$121,868 eastern Oklahoma Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
129
Part B Program Area: Part B Base
5. Provide eligible Part B
clients with transportation services to medical appointments.
One bus token, cab voucher, or volunteer driver service
450
900
Apr 09 –
Mar 10
$35,000 statewide:
$25,067 western Oklahoma
$6,933 eastern Oklahoma
6. Provide eligible Part B clients with dental care services for diagnostic, prophylactic and therapeutic Class 1, 2, and 3 oral health care needs.
One dental visit
450
450
Apr 09 –
Mar 10
$133,630 statewide:
$80,462 western Oklahoma
$53,168 eastern Oklahoma
7. Provide eligible Part B clients with laboratory services in order to monitor HIV disease.
One laboratory service
550
1,050
Apr 09 –
Mar 10
$74,000 statewide:
$44,400 western Oklahoma
$29,600 eastern Oklahoma
One individual, group, or professional counseling session
8. Provide outpatient mental health and substance abuse services through individual therapy, group therapy, or professional counseling.
$147,626 statewide:
$97,626 western Oklahoma
1,200
Apr 09 –
250
Mar 10
$50,000 eastern Oklahoma
One laboratory, dental, or medical specialty service
$337,000
9. Provide specialty primary care services to eligible Part B clients.
$224,000 western Oklahoma
Apr09‐
150
1,200
Mar10
$113,000 eastern Oklahoma
Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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Part B Program Area: ADAP (HIV Drug Assistance Program)
Total Number of Contractors/Providers Funded in FY 2009: 3
Service Goal Statement: To ensure access to HIV/AIDS therapies consistent with PHS guidelines for all eligible Persons Living With HIV/AIDS in Oklahoma.
Quantity:
Objective/s:
Service Unit Definition
Number of People to be Served
Total number of Service Units to be Provided
Time Frame:
FY 2009 Funds Total = $4,278,905 (does not include Administration, Quality Management, Planning and Evaluation):
ADAP Earmark
$3,795,618
Part B Base
$480,287
1. Continue statewide HIV prescription assistance program through the state’s AIDS Drug Assistance Program
One prescription for medication on the program formulary
570
15,321
Apr 09 ‐ Mar 10
$3,869,405
2. Continue prescription co‐pay assistance for medications on the state’s AIDS Drug Assistance Program
One prescription that receives co��pay assistance
300
5,100
Apr 09 ‐ Mar 10
$409,500
3. Provide clinical adherence services to ADAP clients in the Oklahoma City Part C clinic
One service of either initial assessment, follow‐up and routine clinical visit and refill monitoring.
660
2472
Apr 09‐Mar 10
$204,224 Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
131
Part B Program Area: Health Insurance Assistance Program
Total Number of Contractors/Providers Funded in FY 2009: 1
Service Goal Statement: To ensure access to continued health insurance coverage for all eligible Persons Living With HIV/AIDS in Oklahoma.
Quantity:
Service Unit Definition
Number of People to be Served
Total number of Service Units to be Provided
Time Frame:
Objective/s:
FY 2009 Funds
1. Continue
statewide health insurance assistance through the state’s HIV Insurance Assistance Program.
One monthly insurance premium payment
160
1,440
Apr 09‐ Mar 10
$775,600
Part B Program Area: HIV Home Health Program
Total Number of Contractors/Providers Funded in FY 2009: 1
Service Goal Statement: To ensure access to continued health insurance coverage for all eligible Persons Living With HIV/AIDS in Oklahoma.
Quantity:
Time Frame:
FY 2009 Funds
Objective/s:
Service Unit Definition
Number of People to be Served
Total number of Service Units to be Provided
1. Continue statewide HIV Home Health Program.
One skilled nurse visit, personal care visit or DME
15
100
Apr 09 ‐ Mar 10
$25,000

Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
85
CHAPTER 9: Profile of Ryan White Funded Providers by Service Category
Ryan White Providers and Services
The state has two primary “hubs” of service providers—Oklahoma City and Tulsa. Each city has a Part C clinic as well as Part B providers.
Description of Oklahoma City Part B Providers
• The University of Oklahoma Health Sciences Center-Infectious Disease Unit provides comprehensive HIV specialty medical care and coordinated access to health care treatment and support services for infected children, adolescents, men and women with HIV/AIDS, and their affected families residing in the 405/580 area codes (through a combination of Part B, C, and D funding). Part B funded services include laboratory, specialty medical care, medical case management, mental health services, local APA, and treatment adherence. OUHSC also promotes HIV prevention, education, and counseling and testing. These programs link those HIV positive persons who are out-of-care into medical treatment and support services, and decrease the acuity level of these persons.
• The Regional AIDS Intercommunity Network (RAIN Oklahoma) was formed by the January 2005 merger of the Regional AIDS Interfaith Network and CarePoint. Both organizations have been actively engaged in providing services to Oklahomans impacted by HIV/AIDS for well over a decade (RAIN was founded in 1991 and CarePoint in 1993). The merged agency operates from offices in Oklahoma City, Tulsa and Lawton, and provides a continuum of services including HIV prevention education, testing, outreach case management and non-medical case management, housing assistance, nutritional services, and volunteer care teams to clients Statewide. Part B funds outreach case management and non-medical case management in the Oklahoma City and Lawton RAIN offices.
Agency
Primary Medical Care/Labs
Specialty Medical Care
Substance
Abuse/
Mental Health
Dental
Case
Management
Transport-
ation
Local APA
TX
Adherence
Outreach CM
Red Rock BHC
X
RAIN OK
X
X
X
X
RAIN Lawton
X
X
Tulsa C.A.R.E.S.
X
X
OUHSC-IDI
X
X
X
X
X
X
OSU CHS-COM
X
X
X
X
X
X
X
Total
3
2
3
3
5
2
2
1
3 Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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• Red Rock North Behavioral Health Services provides mental health care and the continuum of care for HIV-positive individuals.
Description of Tulsa Area Part B Providers
• The Oklahoma State University-Center for Health Sciences-College of Osteopathic Medicine’s Internal Medicine Specialty Services Program is responsible for providing comprehensive, integrated HIV prevention, primary medical and specialty care and care coordination services for individuals living with HIV/AIDS residing in the 918 area code (through a combination of Part B, Part C and CDC funding). Part B funded services include laboratory, specialty medical, medical case management, local APA, dental and medical transportation services.
• The Tulsa Center for AIDS Resources, Education and Support (Tulsa C.A.R.E.S.) provides services to meet the special needs of those affected by HIV and AIDS. The case management program forms the hub of the direct care service delivery system in the 918 area code. Part B funds support non-medical case management.
Coordination and Linkage with Other HIV Programs
Ryan White Part A: No Part A Eligible Metropolitan Area (EMA/TGA) exists in Oklahoma.
Ryan White Part B: The Part B service providers are RAIN Oklahoma, RAIN Lawton, Tulsa C.A.R.E.S., Red Rock Behavioral Health Services and OUHSC and OSU-CHS-COM.
Ryan White Part B funding is also being used for the HIV Drug Assistance Program (HDAP), the Home Health Care Program and the Health Insurance Assistance Program (HIAP).
Ryan White Part C: Two (2) Part C programs exist in Oklahoma. The University of Oklahoma Health Sciences Center (OUHSC) is the only program in the 54-county Western region of Oklahoma. Oklahoma State University Center of Health Sciences College of Osteopathic Medicine is the Part C grantee for the 23 counties in the Eastern region of the state.
Ryan White CARE Act Part D: OUHSC is the Part D grantee.
AETC: OUHSC is the AETC grantee.
Part F: The dental reimbursement program is administered by OUHSC College of Dentistry.
HIV Prevention: The Oklahoma State Department of Health (OSDH) receives funding for HIV Prevention services from the Centers for Disease Control and Prevention (CDC).
Other:
o HUD-SHP (Housing and Urban Development – Supportive Housing Program)
o HOPWA (Housing Opportunities for People With AIDS)
o Department of Rehabilitative Services Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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CHAPTER 10: Demographics of Part B Clients
Table 39: Comparison of 2007 HIV/AIDS Prevalence & 2007 Part B PLWHA Clients
2007 Epi Profile
2007 Part B Clients
Demographic Group/ Exposure Category
PLWHA as of 12/07
Demographic Group/
Exposure Category
PLWHA as of 12/07
Gender
#
% of Total
Gender
#
% of Total
Male
5011
83.45%
Male
1,458
81.2%
Female
994
16.55%
Female
330
18.4%
Transgender
-
-
Transgender
6
0.3%
Total
6,005
100%
Total
1795
100.0%
Race/ Ethnicity
#
% of Total
Race/ Ethnicity
#
% of Total
2,669
44.45%
White, not Hispanic
1001
55.8%
White, not Hispanic
892
14.85%
African-American, not Hispanic
356
19.8%
African-American, not Hispanic
218
3.63%
Hispanic
149
8.3%
Hispanic
0
0%
Asian/PI
8
.5%
Asian/PI
250
4.16%
American Indian/A.N.
127
7.1%
American Indian/A.N.
0
0%
Multi-race
131
7.3%
Multi-race
1,974
32.87%
Other/Unknown
23
1.3%
Unknown
Total
6,005
100%
Total
1795
100.0% Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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2007 Epi Profile Demographic Group/
PLWHA as of 12/07
2007 Part B Demographic Group/Exposure
PLWHA as of 12/07
Age at Diagnosis (Years)
#
% of Total
Age at Diagnosis (Years)
#
% of Total
<13 years
48
0.80%
<13 years
2
0.11%
13-24 years
794
13.22%
13-24 years
58
3.23%%
25-34 years
2,245
37.39%
25-34 years
314
17.49%
35-44 years
2,035
33.89%
35-44 years
735
40.95%
45-54years
720
11.99%
45-54years
572
31.87%
55-64
140
2.33%
55-64
101
5.63%
65+
23
.38%
65+
13
0.72%
Total
6,005
100%
Total
1795
100%
Adult/Adolescent Exposure Category
#
% of Total
Adult/Adolescent Exposure Category
#
% of Total
MSM
3,019
50.3%
MSM
978
54.5%
IDU
714
11.9%
IDU
165
9.2%
MSM/IDU
662
11%
MSM/IDU
158
8.8%
Hemo/Coagulation Disorder
21
.35%
Hemo/Coag Disorder
4
0.2%
HET
679
11.3%
HET
409
22.8%
Blood Transfusion
42
0.7%
Blood Transfusion
7
0.4%
Risk Not Specified
816
13.6%
RNS/Other
69
3.9%
Total
6,005
100%
Total
1795
100%
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Table 39: Underrepresented Populations in Ryan White Funded Primary Medical Care
Special Population
Overall % in PLWHA
Comparison to ‘In Care’ Population %
Estimated Composition in Out of Care Group
1) African Americans
New AIDS 26% New HIV 32% PLWH 15.3 %
PLWA 15%
19.8% Part B
22.5% Part C
52%
2) Youth, 13-24 years & 20-29 years
New HIV 32.3% (among Youth ages 20-29 yrs) PLWH 22% (among Youth, ages 15-24 yrs)
Youth, ages 13-29 comprise 10.3% of Part B clients
Youth, ages 13-24 yrs comprise only 2.9% Part C clients
PLWH: 13-19 yrs: 73%; 20-29 yrs: 63%
PLWA: 13-19 yrs: 45%; 20-29 yrs: 42%
3) Hispanics
New AIDS 10.5% New HIV 7.1% PLWA 3.8% PLWH 3.4%
8.3% Part B clients
7% of Part C clients
64%
4) IDU
*New AIDS 22% New HIV 17% *PLWA 25% *PLWH 21%
18% of ‘combined’ Part B
18% of ‘combined’ Part C
unk
5) Rural PLWHA
Unknown
16% Part B Clients
Est. 20% Part C
54%
• Proportion of IDU total when combine IDU and MSM/IDU (Source: Column B: OK HARS data, 2007; Column C –2007 CAREWare Data; Column D: 2008 Unmet Needs Assessment)
African American PLWHA
In 2007, Blacks comprised 32% of the new HIV cases, yet there were only 19.8% African American PLWHA in the Ryan White Part B program’s Primary Medical Care service category. (2007 Ryan White CADR) Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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Out of Care/Unmet Need: The level of Unmet Need among African Americans is 2nd among race/ethnic groups at 52%, behind Hispanics at 64%, per a 2008 Oklahoma study.
Barriers to Care Entry: Barriers to care entry include the stigma associated with HIV infection, issues with disclosing risk behavior, concerns about funding of care, and historical misperceptions about antiretroviral therapy.
PLWHA Youth
In 2007, there were 10.3% Youth PLWHA (ages 13-29 years) in the Ryan White Part B program’s Primary Medical Care service category. (Oklahoma 2007 Ryan White CADR)
Out of Care/Unmet Need: Youth evidenced a substantially increased rate for being out of care in 2007, at 42%-73%, depending on HIV or AIDS status and age range (13-19 years versus 20-29 years) according to a 2008 Oklahoma Unmet Need study.
Barriers to Care Entry: Barriers listed by Youth include stigma, perception that they aren’t ‘sick’, and fears related to HIV medications. These fears appear contradicted by their statements that HIV medications can resolve their infection despite delayed entry into treatment.
Hispanic PLWHA
In 2007, there were 8.3% Hispanic PLWHA in the Ryan White Part B program’s Primary Medical Care service category, while Hispanics comprised 10.5% of all new AIDS cases. (Oklahoma 2007 Ryan White CADR)
Out of Care/Unmet Need: Hispanics recorded the highest percent of unmet need or election to stay out of care among all races/ethnicities despite an HIV-positive diagnosis at 64% in 2007.
Barriers to Care Entry: Reasons for the decision not to enter care include undocumented citizenship status, lack of financial resources, stigma related to HIV, and issues surrounding the desire to remain non-disclosed to their spouse and/or family about disease/same-sex relations.
IDU
In 2007, there were 9.2% IDU and 8.8% MSM/IDU (for a total of 18%) in RW funded Part B services, yet IDU and MSM/IDU comprised 17% of HIV incidence, 22% of AIDS incidence, 25% of AIDS prevalence and 21% of HIV prevalence in 2007. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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Barriers to care Entry: Barriers for IDU and substance abusers include continued substance use/abuse and fear of legal entanglements.
Rural PLWHA
In 2007, Rural PLWHA comprised 16% of the Part B funded service delivery system.
Out of Care/Unmet Need: Rural PLWHA, residing in non-MSA localities throughout the state, comprised 54% of the out of care population (compared to the state average of 48%).
Barriers to care Entry: Many barriers act as obstacles to care for Rural PLWHA including transportation difficulties, stigma, and fears of disclosure and lack of confidentiality.
Males, Females, MSM, Heterosexual and American Indians are all ‘In Care’ in proportions that reflect their proportionate representation in the local epidemic.
SECTION II. WHERE DO WE NEED TO GO: WHAT SYSTEM OF CARE DO WE WANT?
Introduction to Section II:
The OHPC plans to focus its actions and those of its partners over the next three years on the further refinement of an ideal continuum of care for all PLWHA in Oklahoma. Efforts to achieve this ideal will result in a continuum that shortens the time between diagnosis and entry into care, facilitates earlier testing and treatment and reduces transmission of the virus to others, lengthens the time between entry into care and transition to AIDS-defined status, reduces the number and severity of complications and episodes of illness and, finally, lengthens the time between HIV diagnosis and death from the virus. Through careful consideration of Oklahoma PLWHAs’ environment, population characteristics, history, needs, care resources, service gaps and barriers to care, the OHPC has developed an ideal continuum of care.
CHAPTER 11: Continuum of Care for High Quality Core Services/Shared Vision & Values
The Mission of the Statewide Coordinated Statement of Need (SCSN): is to identify epidemiological trends, common unmet needs and barriers for persons living with HIV/AIDS throughout Oklahoma and to promote a shared vision for effective planning and coordination of treatment and care services across the state.
OHPC Vision Statement: Over the next three years, the community will enhance (or increase access to) a coordinated system of HIV/AIDS care (treatment) and prevention in order to improve the quality of life for people living with HIV/AIDS in Oklahoma. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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The continuum of care in Oklahoma is defined by those services directly linking newly diagnosed and people living with HIV and AIDS to primary medical care and support services. Services with the highest ranking throughout the prior three-year strategic plan timeframe relate directly to primary medical care entry and retention. (Core Medical Services ranked 1 through 5 in priority). Medical and social support services ranked 6-15 are services determined to facilitate entry into and retention in care based on findings of the 2006 triennial needs assessment.
Mission of the Oklahoma HIV Planning Council: To ensure active, diverse and substantive input and involvement of persons living with HIV and AIDS (PLWHA) in the HIV prevention and care planning processes for the State of Oklahoma. The Oklahoma HIV Planning Council is an important statewide advisory planning body of physicians, community leaders, State agency representatives, service providers, and consumers. Working in partnership with the Oklahoma State Department of Health, HIV/STD Service, they developed the goals of the SCSN and Comprehensive Plan, make recommendations as to the best utilization of the Ryan White Part B funds, and help to develop and maintain a comprehensive continuum of care for those living with HIV disease. After analyzing needs assessments, service barriers, and gaps in services, they submit an HIV service delivery plan for Oklahoma and evaluate these services for cost effectiveness and efficacy of meeting consumer needs. It is the policy and mission of the OHPC to ensure active, diverse and substantive input and involvement of persons living with HIV/AIDS (PLWHA) in the planning process. PLWHA have a unique understanding of service needs, which make them essential participants in the planning and oversight of services. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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OHPC TREATMENT ADHERENCE MCM PMC MENTAL HEALTH CARE SUBSTANCE ABUSE TREATMENT Non‐MedicalCM MEDICALTRANSP CONSUMERORAL HEALTH CARE MEDS OKLAHOMA Ryan White Part B Ideal Continuum of CareSPECIALTY MEDICAL CARELAB Other Ryan White Part C, D, F & Non‐RW Funding Streams: MCD, MCR, DHS OEPIC, DHS Advantage, etc Other Medical/ Support Services: 330b; Indian Health Services; MCD Transport: HOPWA; Section 8, Food stamps, etc PREVENTION, T & C & EIS/OUTREACH CM & REFERRAL LINKAGESOklahoma State Department of Health 2009‐2011 Comprehensive Plan
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SECTION III: HOW WILL WE GET THERE: HOW DOES OUR SYSTEM NEED TO CHANGE TO ASSURE AVAILABILITY OF AND ACCESSIBILITY TO CORE SERVICES?
CHAPTER 12: Planning within the State of Oklahoma
The purpose of this section is to provide a road map that will refine and continuously improve the Oklahoma HIV care and support services delivery system. The proposed care system has been created to be responsive to the changing needs of the epidemic and fill the service gaps of PLWHA who know their status and are not in care. The Plan effectively responds to HRSA/HAB’s over-arching goals ‘to increase access to care to 100% and reduce outcome disparities to 0%’. It provides guidance as to how our system needs to change to assure availability of and accessibility to core medical and other support services.
As the continuum of care in Oklahoma continues to evolve, core values and shared visions are utilized to guide and direct the service delivery planning process for PLWHA. Utilizing these guiding principles (Mission and Shared Vision) and other pertinent information such as the HRSA planning requirements, the Statewide Coordinated Statement of Need (SCSN), and results from the regional and statewide needs assessments, the OHPC formulated the following goals and objectives for the next three years. The following sections will include:
􀂾 A narrative description of the goals of the SCSN and Plan, and
􀂾 A summary table of each goal, accompanied by objectives and actions with
specified timeline and responsible party.
The central purpose of the Ryan White Part B funding is facilitating PLWHA access into and retention in care and ensuring that they are supported in adhering to their medical regimens. Therefore, at the core (center) of the model are both medical care and the supportive services that help PLWHA to engage with and remain in care.
Because it is important that these various medical and support services be delivered in a coordinated and consistent manner, the care circle is surrounded by services that facilitate or arrange access to medical and supportive services. This core of medical, supportive, and coordination services exists in the context of goals that promote access to care for all those living with HIV/AIDS and ensures that high-quality services are provided in a cost-effective manner. The entire continuum of care is specifically designed to result in improved health outcomes.
Extensive planning contributed to development of the updated comprehensive plan, with Ryan White and other service provider, community involvement and PLWHA input. Developing goals for the integrated 2009-2011 SCSN and Comprehensive Plan was a data-driven process. The preliminary goals presented in this document were developed based on consumer and provider input; epidemiologic and other data from the Oklahoma State Department of Health; detailed In Care and Out of Care consumer survey results from the 2006 Needs Assessment, and preliminary Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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results from the 2009 prevention prioritization process. Additional data sources include information from the last Statewide Comprehensive Statement of Need and Statewide Comprehensive Prevention Plan, with final input from the Planning Council.
The OHPC members and invited guests spent a day-long planning session to review and refine the short-term and long-term goals for the integrated SCSN and Comprehensive Plan. The Oklahoma HIV Planning Council is responsible for assuring that the plan’s goals are met with the suggested objectives and tasks assigned. In addition, in collaboration with OSDH,
the Care Committee is responsible for:
1) Implementing the specific tasks required to meet the goals;
2) Monitoring the tasks required to meet the goals using measurable indicators; and
3) Performing outcomes evaluation on the goals in the plan.
Cross Cutting Issues
Cross-cutting issues identified in the day-long statewide planning process and common to all Ryan White Program Parts across the State include extreme poverty, high levels of un-insurance, substantial co-morbidity, drug use, lack of transportation, lack of affordable housing, lack of knowledge about services available, stigma, discrimination, fears of disclosure and lack of confidentiality. Also noted was the continued high level of unmet need, the rising cases of HIV/AIDS among Youth, and the disproportionate impact among Blacks.
In addition to the findings already mentioned, several needs, gaps and challenges were also
Identified, as follows:
1) The need for integrated, interdisciplinary and co-located approaches to care and support services;
2) Multi-cultural, multi-disciplinary teams that integrate to the extent possible medical care, including specialty care, with mental health, substance use treatment, case management and other HIV- related support services can best manage the complex medical and social issues faced by PLWHA and their affected families. Ideally, services are co-located or, at a minimum, stronger working relationships are forged between programs.
3) The need for case management training in performing expanded behavioral risk assessment and risk reduction education that is age appropriate and culturally competent
4) The increased complexity of care and costs associated with multiple co-morbidities diagnoses (MH, SA, Hepatitis, STDs, diabetes and heart disease) which translates into an on-going need for cross-training of staff, co-location of services wherever feasible, and frequent case consultation.
5) Long distances to travel for rural PLWHA combined with weak public transportation infrastructure creates access barriers for rural PLWHA.
6) Shortage of dentists who accept Medicaid and need for expanded oral health services.
7) The need for stronger linkages between prevention and care – referrals and retention in care.
8) The need for community-based social marketing efforts to reduce stigma and inform consumers of benefits of testing, treatment and care.
9) The need for ongoing Provider staff education in cultural competency. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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10) The need for greater CM training in accessing all available third party resources.
11) The need for RW and non-RW provider training in facilitating client access to all available medical and support services.
12) The need for continued training in Data management systems and Quality Management & Evaluation
Conclusion
The steady expansion and changed demographics of the HIV epidemic, as well as improved survival time for people living with AIDS are placing increased stress on state and local health care systems. The State of Oklahoma, through this integrated SCSN and Comprehensive Plan document, outlines the need for collaboration among all Ryan White grantees. This collaboration is based on needs assessment findings, goals and objectives of the Oklahoma HIV Planning Council and evaluation/monitoring of HIV/AIDS providers. The overreaching goal for all Ryan White Parts is to link/re-engage in primary medical care those individuals who know their positive HIV status. As all of the Ryan White funded entities respond to the numerous challenges in delivering quality HIV care for an expanding patient population, the collaborative focus on reducing health care disparities, bringing the out of care in to care while maintaining a comprehensive continuum of care is critical. Only through ‘all Part’ collaboration can these challenges be overcome.
Narrative Summary of 2009 Service Delivery Goals
Goal 1: Improve Access to Health Care
An ideal, comprehensive care system ensures that geographical, socioeconomic, or infrastructure obstacles that prevent PLWHA from accessing that system are minimized or eliminated. A variety of regional and Statewide collaborative strategies, along with targeted marketing, outreach and early intervention programs are designed to overcome barriers to care, including PLWHA not knowing how or where to obtain care, not knowing what services are available through Ryan White, or lacking the knowledge or skills in how to navigate the benefits and services available in Oklahoma. EIS case management staff also serve those out of care by addressing their concerns about stigma and other issues that may keep them from seeking care. Outreach is strongly linked to early intervention services, with the goal of facilitating earlier access to care and shortening the interval between testing and care entry.
Only 52% of Oklahoma’s PLWHA have a met need for HIV primary medical care. Ensuring access to all needed core medical services, including adequate levels of Oral Health Care, acceptable and accessible Mental Health and Substance Abuse treatment services, and providing the necessary transportation assistance to access needed services represent top goals for the new plan. The measures of the efficacy of this HRSA strategy include the increasing number/percentage of the HIV-positive population (including each of the special populations) who are entering care each year, encouraging earlier entry into care and reducing time from Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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testing to care, and effectively retaining in care all special populations living with HIV disease in Oklahoma.
Goal 2: Eliminate Health Disparities
African Americans, Hispanics, Males, MSM, and Youth evidence an increasing and disproportionate impact of HIV/AIDS in Oklahoma. (Oklahoma Epidemiologic Profile,2008).
The level of Unmet Need, or the percent of PLWHA not in care that know that they are HIV-positive, is highest for African Americans, Hispanics, Youth and Rural residents per a study conducted in 2008 by the Oklahoma State Department of Health. The Statewide level of unmet need is approximately 48% for 2007 (Oklahoma Unmet Need Study, 2008). The OHPC reviews these reports and other sources of information (such as needs assessments and information from the community), and issues directives aimed at eliminating health disparities. Ensuring urban and rural parity in access to core medical and support services and the co-location and high level collaboration between providers to jointly manage PLWHA’s HIV disease management and other co-morbidities facilitates successful engagement and retention in care for all the underserved populations in Oklahoma.
Implementing best practice strategies which result in more ‘youth-friendly’, women-friendly’ and ‘minority-friendly’ care environments encourages entry into and retention in care. The measures of the efficacy of this HRSA strategy include the increasing number/percentage of the urban and rural underserved populations who are entering into and receiving care, combined with steady reductions in the level of unmet need, especially among the special populations.
Goal 3: Improve the Quality of Health Care
Higher-quality core medical care and support services are more effective at interrupting the progression of HIV disease and in preventing/reducing complications of the disease while contributing to quality of life and reducing the further spread of the disease. The Continuous Quality Management Program will monitor provider performance against PHS standards of care and provide training and technical assistance to all Part B providers as needed.
The OHPC in 2009 will review the quality improvement service category reports, and consider consumer needs and category performance and history as well as other funding streams available to a category when making allocation and reprogramming decisions. The measure of the efficacy of this HRSA strategy is evidenced by: 1) the integration of quality management processes and standards of care for all Part B funded services; 2) the increasingly knowledgeable and informed Part B providers and Consumers who are involved in continuous quality improvement activities; 3) compliance with public health standards; and 3) continuous performance improvements in key health indicators annually.
Goal 4: Assure Cost Effectiveness
The expenditure of Part B funds must occur after all other resources are exhausted and must assure the maximum possible impact for each dollar expended. The OHPC and its committees review expenditure and service delivery reports to assess trends in utilization of funds, services Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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provided, and costs per service category/units of service. OSDH provides expenditure and service reports to the OHPC regularly throughout the year. Where funds in a service category are under-expended, the OSDH re-programs the under-spent funds to other categories that have demonstrated need.
The Oklahoma HIV Planning Council collaborates with other funding streams to assess any duplication of services, and strives to reduce/prevent unnecessary duplication in funding streams. The measures of cost effectiveness include: 1) a PSRA process which documents use of Part B funds to fill service area gaps; 2) demonstrated maximal use of other funding streams to support the continuum of care while achieving reductions in costs per service category uses; and 3) a system of care that continues to expand access to meet the increasing demand, evidenced by a continuously expanding Part B client population in care.
Goal 5: Improve Health Outcomes
This goal sums up the overall effectiveness of both the Ryan White Part B program, and the effectiveness of all partners who serve HIV-positive consumers in the Oklahoma planning area. Outcomes for the specific service categories are interim measures of effectiveness. Outcome measures selected for measurement and reporting in the upcoming fiscal year include numerous indicators of importance to the men, women and youth to be served, including the number/percent of PLWHA with CD4 cell counts below 200 who are appropriately prescribed PCP prophylaxis and the number/percent of PLWHA on ART who achieve and maintain an undetectable viral load during the project year. Other outcome measures include the increasing number/percent of female PLWHA who receive annual Pap smears and pelvic exams and appropriate referrals; the increasing number/percent of PLWHA who receive TB testing each year, and are appropriately treated for latent and active Tuberculosis; and the decreasing number/percent of the client population that develop an AIDS diagnosis during the project year.
The ultimate health outcome measures include a reduction in emergency room and hospitalization rates and increasing survival rates/reduction in death rates due to AIDS. Improvements in quality of life outcomes to be tracked and reported include reported increases in overall health and reports of increased employment among HDAP clients.
These goals form the basis for the triennial comprehensive plan, with emphasis on the following four core themes:
1) Reduced Unmet Need, effectively moving the out of care into HIV primary medical care;
2) Increased access to care, especially among the emerging and special populations;
3) Reduced disparities in health care access and outcomes for the emerging and historically underserved populations; and
4) Continuous quality improvement, including its direct relationship to client level data and provider performance data, and positive impact on health outcomes.
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CHAPTER 13: Goals, Objectives, and Activities
This chapter identifies the Oklahoma Part B goals, and the plans to accomplish those goals during the 2009-2011 time frame, through specially developed strategies and action steps that are responsive to the state’s current situation and statewide assessment of needs, in order to meet the measurable objectives of the stated plan. This plan was developed in keeping with the HRSA guidance at the forefront, and will provide guidance to the OHPC over the next three years. The implementation plan orchestrates numerous strategies and implements new and continuing initiatives, based upon the considered needs of Oklahoma PLWHA in achieving the ideal continuum of care. All of the proposed activities include consideration of cost effectiveness and quality, so that the health outcomes of those served may continue to evidence the desired improvements.
2009 HRSA Expectations for Comprehensive Plan
Table 40. 2009 HRSA COMPREHENSIVE PLAN EXPECTATIONS
1. Ensure the availability and quality of all core medical services within the service area.
2. Eliminate disparities in access to core medical services and support services for individuals with HIV among disproportionately affected sub-populations and historically underserved communities.
3. Specify strategies for identifying individuals who know their HIV status but, are not in care, informing them about available treatment and services, and assisting them in the use of those services.
4. Include a discussion of clinical quality measures.
5. Include strategies that address the primary health care and treatment needs of those who know their HIV status and are not in care, as well as the needs of those currently in the HIV/AIDS care system.
6. Provide goals, objectives, timelines and appropriate allocation of funds (as determined by the needs assessment).
7. Include strategies to coordinate the provision of services programs for HIV prevention, including outreach and early intervention services.
8. Include strategies for the prevention and treatment of substance abuse.
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Short Term Goals and Long Term Goals of the 2009-2011 Oklahoma Part B Comprehensive Plan
a. Chart of Short Term Goals, Objectives, Timelines and Responsible Parties
The OHPC, in collaboration with OSDH, has identified the following 6 goals, 14 objectives and 44 activities as its action plan aimed at developing the ideal continuum of care in Oklahoma.
1
Goal # 1: Improve Access to Health Care Services
Objective 1.1: Increase access to care by 10% annually for PLWHA populations by creating more capacity for navigating and understanding care systems and other resources for services. (Baseline: 2008 New & Returning Part B Clients=1,795: Target 180 New Part B Clients with 36 new AA; 15 new Hispanic; 19 new Youth; 33 new Female; 29 new Rural and 32 new IDU clients)
Timeframe
Responsible Person(s)
Activity #1.1.1.Create and widely disseminate an updated PLWHA Resource Guide to all points of entry, including C/T, outreach, primary medical and specialty providers & other key providers & locations.
Q 1-2, Update Annually
OHPC & Committees
Activity #1.1.2. Develop referral protocols and improve communication between HIV CTR, case management, and medical staff to ensure referrals/ follow-ups are provided to newly positive clients.
Q 1, 2, 3 ,4
OSDH
Activity #1.1.3. Encourage RW Part B/C PMC, CM & MH/SA providers to implement ‘opt out’ HIV testing as an element of routine care.
Quarterly/
Annually
OSDH
Activity #1.1.4. Explore evidence-based interventions, support proposals and pilot innovative alternative models for engaging SNG clients in care.
Bi-Annually
OSDH
Objective #1.2: Reduce lag time from testing to care by 5% annually to speed entry into care for all newly diagnosed PLWHA populations and especially SNGs (Establish Baseline: 2008 Delays in Months from Testing to Care, by special population, through cross-match of PEMS and CAREWare data bases)
Timeframe
Responsible Person(s)
Activity #1.2.1.Confirm ‘Points of Entry’ & Strengthen Testing/Counseling & Referrals to Care linkages; ensure follow-up tracking strategies for referral confirmation.
Q 1-2
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Activity #1.2.2. Perform ‘Late to Care’ study as part of comprehensive 2009 In Care Needs Assessment; evaluate results and implement strategies to reduce identified barriers to care.
Q 1-4
OSDH
OHPC
Activity #1.2.3.Explore best practice peer advocacy/support models to facilitate earlier care entry & enhance care engagement among underserved populations.
Q 1-2
OHPC
Activity #1.2.4.Explore various client-centered models of care, & best practices, with emphasis on increasing ‘women’, ‘youth- ’ and ‘minority-friendly’ care environments.
Q 1-2
OHPC
Activity #1.2.5.Srengthen coordinated linkages with non- RW providers across the life span to facilitate mutual referrals and increased cross-collaborations, including IHS.
Q 2-3
OSDH
Activity #1.2.6. Explore barriers to obtaining dental care services, and implement solutions to address access issues.
Q 2-3
OSDH
OHPC
2
Goal # 2: Reduce Health Care Disparities
Objective #2.1: Reduce Level of Unmet Need by at least 2.5% Annually. (Baseline: 2008 Unmet Need=48%or 2,722: Target 90 OOC annually for total of 270 or 10% reduction in unmet need over next three years)
Timeframe
Responsible Person(s)
Activity #2.1.1. Complete an Unmet Study surveying the Out of Care populations.
Q 1-2
OSDH
OHPC
Activity #2.1.2. Address OOC Service Gaps & Barriers.
Q 3-4
OSDH
OHPC
Activity #2.1.3. Develop and implement target messages to overcome SNG barriers to care entry, and particularly for AA MSM.
Q 3-4
OHPC
Activity #2.1.4. Require bi-annual provider assessments of those who are out of HIV primary care and require providers to contact them and facilitate re-entry into care.
Q 2-4
OSDH
Activity #2.1.5. Increase utilization of peer mentors to strengthen access, engagement & retention in care among SNGs.
Q 2-4
OSDH
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Activity#2.1.6. Continually assess demographic profile of Part B clients to assure that disproportionately affected subpopulations and historically underserved communities are accessing core medical services.
Quarterly,
Ongoing
OSDH
OHPC
Objective #2.2: Evaluate Barriers to MH/SA Services and Address HIV Disease and Co-Morbidity Management among New and Returning Part B clients.(Baseline: Part B Clients assessed as needing MH/SA services compared with # of confirmed referrals)
Timeframe
Responsible Person(s)
Activity #2.2.1. Identify and implement best practice CM & PMC models to overcome the barriers to MH/SA services and improved protocols to retain mentally ill clients in care.
Q 1-2
OSDH
OHPC
Activity #2.2.2. Provide CM trainings directed toward increasing skills in accurately assessing, screening and appropriately referring clients for needed MH/SA services.
Q 2-3
OSDH
Activity #2.2.3. Identify and engage potential partners for the provision of expanded oral health, transportation, and in-patient and out-patient MH/SA treatment services.
Q 2-3
OHPC
Objective #2.3: Ensure parity of urban/rural service delivery, including assurance of access to services by non-MSA and rural residents.
Timeframe
Responsible Person(s)
Activity # 2.3.1 Ensure access to core medical and key support services for rural residents through increased coordination of RW and non-RW service providers, including IHS and 330b referrals and collaboration.
Q 2-3
OSDH
Activity #2.3.2 Explore all available transportation resources; explore innovative approaches to transportation assistance and provide resource information/education to clients and providers, to ensure enhanced access to care.
Q 2-3
OSDH
OHPC
Objective#2.4 Increase by 5% annually the number of Part B Clients retained in Primary Medical Care
(Baseline: Proportion of 2007 Part B Clients retained in care in 2008)
Timeframe
Responsible Person(s)
Activity#2.4.1 Assess cultural competency technical assistance and training needs of Part B providers and deliver TA to increase capacity to effectively serve/retain in care the disproportionately affected populations.
Ongoing
OSDH
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Activity 2.4.2. Engage AETC in the provision of CM and PMC provider trainings on resources available and increasing mutual referrals and collaborations with RW & non-RW providers and systems of care.
Q 2-4
OSDH
OHPC
Activity 2.4.3. Explore and implement evidence-based interventions directed toward Severe Need Groups to facilitate initiation and retention in medical care (prevention case management, outreach case management, interventions specific to African American MSM).
Ongoing
OSDH
OHPC
Objective #2.5 Reduce the further spread of HIV infection through enhanced primary & secondary prevention efforts in case management and primary care settings.
Timeframe
Responsible Person(s)
Activity #2.5.1. Assess the TA needs of providers and ensure each has the skills and resources to integrate effective and continuous sexual and drug use risk assessments and risk reduction counseling services for PLWHA clients and their sex and drug using partners.
Ongoing
OSDH
OHPC
Activity #2.5.2. Incorporate more education and prevention messages into the medical treatment of those living with HIV/AIDS.
Annually
OSDH
OHPC
Activity #2.5.3 Develop an action plan for ensuring clients have greater access to needs assessments.
Ongoing
OSDH
OHPC
Activity#2.5.4 Ensure ‘Voice of the Consumer’ in OHPC representation and inclusion in program planning and evaluation activities.
Ongoing
OHPC
Committees
3
Goal # 3: Improve the Quality of Services
Objective #3.1: Implement 2009 Quality Management Plan inclusive of al indicated Provider and Consumer CQI Trainings by December 2009
Timeframe
Responsible Person(s)
Activity #3.1.1. Implement and evaluate the comprehensive QM Plan and results for all Part B services.
Q 1,2, 3, 4
OSDH
OHPC
Objective #3.2:Strengthen Medical Case and Non-Medical Management Care and Systems
Timeframe
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Activity #3.2.1.Conduct quality improvement trainings with Part B providers and consumers, complete performance audits of all CM providers, and implement CQI TA activities to address performance improvement issues.
Q 1,2,3,4
OSDH
Objective #3.3:Ensure Adequate Levels of Medical & Non- Medical Case Management Services to Support Access to & retention in Care
Timeframe
Responsible Person(s)
Activity #3.3.1.Conduct assessment of CM provider capacity and capability and use findings to inform system improvements.
Q 2-3
OSDH
Objective #3.4:Implement and Evaluate System-wide Client Level Data Reporting
Timeframe
Responsible Person(s)
Activity #3.4.1.Implement the system-wide strategy to collect, track and report HRSA client level data.
Q 1-4
OSDH
Activity #3.4.2.Analyze piloted results, refine strategies and evaluate first year client level data collection and reporting efforts for ways to continue to improve the process.
Q-2-4
OSDH
4
Goal #4 : Ensure Cost Effectiveness of Service Delivery
Objective #4.1:Ensure Effective Utilization of Part B Funds to fill Service Gaps and Reduce Disparities in Care
Timeframe
Responsible Person(s)
Activity #4.1.1.Compile and assess all services funding streams and encourage funds diversification to maximize utilization of Part B funds and optimize the further expansion of the Oklahoma continuum of care.
Annually
OSDH
OHPC
Activity #4.1.2.Evaluate core and support funding splits and evaluate unit costs for services across providers and service categories, to inform cost effectiveness considerations, and ensure the most appropriate expenditure of Part B funds.
Annually
OSDH
OHPC
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Activity #4.1.3.Provide ongoing 3rd party reimbursement resource acquisition and benefits trainings to all CM providers to ensure maximal use of all other available resources.
Ongoing
OSDH
Activity #4.1.4.Review service utilization data to ensure appropriate allocation of funds and expenditure of funds with no carry-over.
Quarterly
OSDH
OHPC
Activity #4.1.5. Perform annual priority setting/resource allocation process based on multiple programmatic and fiscal data sets.
Annually
Care Committee
5
Goal # 5: Improve Health Outcomes
Objective #5.1:Increase by 10% annually Part B achievement of improvements in key health outcome indicators, as evidenced by individual level client data and aggregate provider data (Baseline: 2007/2008 QM Results)
Timeframe
Responsible Person(s)
Activity #5.1.1. Evaluate effectiveness of 2009 priority CQI activities (directed toward PCP prophylaxis, Oral health visits and CM visit documentation improvements) and their impact on clinical performance measures & health outcomes.
Quarterly
Annually
OSDH
Activity #5.1.2. Implement key CQI projects to address low scoring performance measures.
Q 3-4
OSDH
Activity #5.1.3. Develop systems to track and report health outcome improvements including 1) reduced deaths due to AIDS/increased survival rates; 2) increases in quality of life as measured by increases in HDAP clients reports of improved health and return to employment.
Q 2-4
OSDH
Activity #5.1.4.Utilize the CAREWare system to generate client level health outcome indicator reports, disseminate findings, and use data to inform system improvements.
Bi-annually
OSDH
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6
Goal #6: GOAL: To Improve the Service Delivery System in the State
Objective 6.1: Ensure the planning process has wide community participation and is consumer driven
Timeframe
Responsible Person(s)
Activity 6.1.1. Conduct a full In Care/Out of Care/Late to Care needs assessment triennially (‘Voice of the Consumer’) with special studies in between.
Q1 2009, 2010 & 2011
OHPC
Activity 6.1.2. Ensure the OHPC is reflective of the epidemic and develop strategies to receive regular and in-depth input from consumer-based and regional community-based groups.
Q2, 2009
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LONG-TERM GOALS AND OBJECTIVES (Over 3-year period: FY 2009 – 2011)
STRATEGIES/ACTIVITIES
Timetable
Responsible
I. INCREASE ACCESS TO CARE
FY
’09
FY
’10
FY
’11
A. Increase Access to Care by 10% Annually Among All Population (N=180) and 10% each of Special Populations/SNGs (Baseline: 2008 Part B Clients)
Conduct community-wide services and funding Inventory & Develop/Distribute Consumer Resource Guide
􀂄
Grantee
Strengthen outreach & HIV testing/counseling and early intervention services & referral linkages in urban/rural venues targeting high risk & aware/not in care
􀂄
􀂄
Grantee
Council
Grantee
Encourage & support PMC , CM & other core medical providers to implement ‘opt out’ HIV testing
􀂄
􀂄
Grantee
Explore and Support Proposals/pilot innovative strategies to increase client engagement in care/Increase use of Peer mentors
􀂄
􀂄
􀂄
B. Encourage earlier Care Entry & Reduce Lag Time from Testing to Care by 5% Annually for all Newly Diagnosed PLWHA
Confirm ‘points of entry’ and strengthen Testing/Counseling to Care linkages
􀂄
􀂄
Grantee
Council
Explore best practices and pilot innovative models of care that encourage earlier entry and retention in care for youth, men, women and minorities, and particularly AA MSM.
􀂄
􀂄
Council
Strengthen coordinated linkages with non-RW providers of services across the lifespan to increase mutual referrals and care sources
􀂄
􀂄
􀂄
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STRATEGIES/ACTIVITIES
Timetable
Responsible
II.REDUCE HEALTH CARE DISPARITIES
FY
’09
FY
’10
FY
’11
A. Reduce Level of Unmet Need by at least 2.5% Annually
Council
Conduct ‘Out of Care’ study, analyze findings and use priority setting process to implement changes in Service Delivery System
􀂄
􀂄
Continuously assess demographic profile of Part B clients to assure that disproportionately impacted and historically underserved are accessing services
􀂄
􀂄
􀂄
Grantee
Council
B. Evaluate Barriers and Address HIV Disease and Co-Morbidity Management among New and Returning Clients
Conduct study of barriers to usage of existing MH/SA services and explore best MCM/CM & PMC practices to jointly address MH and SA needs among Part B clients
􀂄
􀂄
Council
􀂄
􀂄
􀂄
Grantee
Identify and engage state & CBO partners for the provision of expanded transportation, oral health, and outpatient and inpatient MH & SA services
Council
C. Ensure Parity of Urban/Rural Service Delivery, including Assurance of Transportation/Oral Health services for Urban and Rural Residents
Increase collaboration and coordination of RW and non-RW providers, and expand transportation assistance to create more parity between urban/rural care resources
􀂄
􀂄
􀂄
Council
D. Increase by 5% Annually the number of Part B Clients Retained in Primary Medical Care
Refine coordination & linkage of Outreach, Case Management and Primary Medical Care
􀂄
􀂄
􀂄
Grantee
Council
Evaluate and implement numerous strategies to positively impact PLWHA retention in care
􀂄
􀂄
􀂄
Grantee Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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STRATEGIES/ACTIVITIES
Timetable
Responsible
E. Reduce the Further Spread of HIV Disease through Enhanced Primary & Secondary Prevention Linkages and Programs
FY
’09
FY
’10
FY
’11
Assess and address TA needs of providers to ensure competency in performing serial risk assessments and providing risk reduction education and counseling for PLWHA and their sex and drug using partners
􀂄
􀂄
􀂄
Grantee
Incorporate more education and prevention messages into the medical treatment of those living with HIV/AIDS
􀂄
􀂄
􀂄
Grantee
III. IMPROVE QUALITY OF SERVICES
A. Strengthen & Refine Medical and Non-Medical Case Management Services and Systems
Conduct CM Trainings and implement improvements
􀂄
􀂄
􀂄
Grantee
B. Implement 2009 CQI trainings and performance audits of MCM and non-medical CM providers.
Implement TA activities to address performance improvement issues
􀂄
􀂄
􀂄
Grantee
C. Ensure Adequate levels of Medical and Non-Medical Case Managers to support Access and Retention in Care
Conduct assessment of CM provider capacity and use findings to inform the system changes/improvements
􀂄
􀂄
􀂄
Grantee
Council
D. Implement and Evaluate System-Wide Client Level
Data Reporting
Implement, evaluate and continuously refine client level data reporting system and provide TA and guidance as indicated.
􀂄
􀂄
􀂄
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STRATEGIES/ACTIVITIES
Timetable
Responsible
IV. ENSURE COST EFFECTIVE SERVICE DELIVERY
FY
’09
FY
’10
FY
’11
A. Ensure Effective Utilization of Part B Funds to fill Service Gaps and Reduce Disparities in Care
Assess all funding streams, encourage maximize utilization of Part B funds and expand continuum of care.
􀂄
􀂄
􀂄
Grantee
Council
Review funding split between core and support services
􀂄
􀂄
􀂄
Council
Analyze accessibility/quality/utilization of core services in service delivery system
􀂄
􀂄
􀂄
Council
Conduct priority setting/resource allocation process
􀂄
􀂄
􀂄
Council
V. IMPROVE HEALTH OUTCOMES
A. Increase by 10% Annually in Part B Provider Improvements in Key Health Outcome Indicators, as Evidenced by Client Level Data Sets
Review/Refine Standards of care for Part B funded Case Management services, perform chart audits, compare findings to HRSA performance expectations, and implement corrective plans
􀂄
􀂄
􀂄
Grantee
Utilize CAREWare system to generate client level health outcomes indicator data, disseminate findings, and use the data to inform system improvements
􀂄
􀂄
􀂄
Grantee
Ensure OHPC is consumer-driven and reflective of epidemic Ensure widespread consumer and provider input
􀂄
􀂄
􀂄
Grantee
Council
Utilize multiple sources of data for evaluation and planning
􀂄
􀂄
􀂄
Grantee
Council
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STRATEGIES/ACTIVITIES
Timetable
Responsible
VI. IMPROVE SERVICE DELIVETY
FY
’09
FY
’10
FY
’11
A. Ensure the planning process has wide community participation and is consumer driven
Assure mechanism to involve Part B Clients in Needs Assessment Activities
􀂄
􀂄
􀂄
Grantee
Council
Conduct a full needs assessment triennially (‘Voice of the Consumer’) with special studies in between
􀂄
􀂄
􀂄
Grantee
Council
Ensure the OHPC is reflective of the epidemic and develop strategies to receive regular and in-depth input from consumer-based and regional community-based groups.
􀂄
􀂄
􀂄
Grantee
Council
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SECTION IV. How will we monitor our progress?
Introduction to Section IV: Multiple persons and many agencies have a role in implementing the goals of the 2009-2011 SCSN and Oklahoma Comprehensive Plan. The primary responsibility for ensuring that the plan is implemented, and for monitoring its implementation, falls to the OHPC’s Care Committee, in collaboration with the Oklahoma State Department of Health. However, the planning and implementation of the three-year plan requires the full cooperative effort of all Ryan White and other planning and provider partners across the state.
CHAPTER 14: Implementation, Monitoring and Evaluation Plan
Implementation Processes
The Oklahoma HIV Planning Council (OHPC) uses several processes to accomplish the various strategies identified in the action plan. These processes are identified below.
OHPC Leadership Activities
Although the Planning Council performs most of its work through a committee structure, council leadership is responsible for spearheading collaborative activities with OSDH partners.
OHPC Committee Activities
Each OHPC committee has ongoing responsibility for one or more HRSA- and/or CDC--mandated activities. Within these mandates, committees target their activities to accomplish plan strategies.
The Executive Committee is comprised of the Community Co-Chair, OSDH Co-Chair, Two Ex-Officio members of the HIV/STD Service staff (Director of Prevention and Intervention and Director of the Division of Surveillance and Care Delivery) and the Chairs of the OHPC Committees.
• The Membership Committee focuses its council membership recruitment efforts toward engaging wide consumer involvement and the necessary talent and leadership required to fill the voting seats and encourage their full participation in council activities.
• The Assessment and Evaluation Committee monitors special needs assessment studies and reviews reports it has requested. This committee is responsible for evaluating the needs for HIV prevention and care in Oklahoma and for tracking current and future trends in HIV infection. This committee also tracks and evaluates care funded services and expenditures and reviews quality of care reports, making recommendations for improvements. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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• The Policy Committee develops and recommends policies for the operations of the OHPC, including but not limited to Conflict of Interest, Grievance, and Confidentiality policies, as well as developing various operating and other procedures.
• The Care Committee is responsible for assisting in the planning and reviewing of Ryan White funded services and assisting OSDH with the development of the Comprehensive Strategic Plan and Statewide Coordinated Statement of Need. The Care Committee’s planning processes include the analysis of multiple data sources including consumer assessments of need, service expenditures by category, service utilization and quality improvement data. The Care Committee also contributes a portion of the Comprehensive HIV Prevention Plan which pertains to accessing all available care and services.
• The Prevention Committee is responsible for the prioritization of HIV prevention target populations and a set of prevention interventions for each target population, as well as the presentation of this information to the OHPC. The committee also completes a portion of the Comprehensive Strategic Plan that addresses these items.
Provider Contracting and Contract Monitoring Process
OSDH establishes contract conditions of award and monitors Part B contract performance. Some planning council directives are included among the conditions of award, and are subsequently monitored. Monitoring is performed both by review of documents submitted by providers and by OSDH site visits to providers.
The Oklahoma Part B site-visitation process is comprehensive and occurs at least bi-annually to:
1) Review the agency’s/program’s capacity and effectiveness in delivering HIV care and services according to the Part B legislation and guidance;
2) Review the program’s effectiveness of service implementation in accordance with the goals and objectives specified in the grant application/contract;
3) Assess consumer satisfaction and level of involvement in the program;
4) Identify areas of strengths and areas of needed improvement(s) in service delivery;
5) Identify best-model practices;
6) Ensure compliance with the all Part B Standards of Care; and
7) Make recommendations for technical assistance aimed at improving the quality of care and services and continued compliance with Part B funding guidelines.
Monitoring and Evaluation
The OHPC is the body primarily responsible for the development of this plan and, in collaboration with OSDH will ensure the plan’s implementation, monitor its components and evaluate the proposed goals, objectives and strategies.
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CHAPTER 15: Improving Client Level Data
The Quality Committee is fully implementing the new client level data system collection which started in January 2009. The OSDH has been using CAREWare since 2001 to track services and client information, so providers are very accustomed to collecting and reporting client level data to OSDH. Challenges currently revolve around collecting more detailed clinical information in CAREWare from medical providers. OSDH did incorporate the performance measures into their most recent contracts with medical providers, and the Manager of Care QA and Data Analysis has been reinforcing the importance of clinical documentation in CAREWare. Missing data reports are available to providers and with providers being centralized on the main server at OSDH, the Manager of Care QA and Data Analysis can create reports and copy them to providers to run as needed to improve data quality. In addition, Performance Measures Groups 1 and 2 are available to all providers in CAREWare to perform at any time at the click of a button. The grantee provided training to all providers on the RDR and RSR systems in January and reviewed with each the required data elements and new clinical information required. The Manager of Care QA and Data Analysis (in addition to data quality staff from a large medical provider) participated in the RDR/RSR training from HRSA.
The OSDH will use CAREWare to generate an export file that can be directly uploaded to the RSR system. Currently all medical and non-medical providers use CAREWare to enter service data so uploading medical and non-medical case management provider and client data is not an issue. OSDH’s focus will be on ensuring data completeness and accuracy, especially focusing on screenings and detailed clinical information that is needed.
Currently, the OSDH has conducted baseline analysis of performance measures and has identified areas for improvement using the Performance Measures Module in CAREWare or RDR. Data is incomplete for some clinical variables so the QC will work with providers to improve the data completeness. These measures will provide evidence of performance over time and assist the grantee with identifying areas for improvement with services and quality of care. Overall, the performance measures are consistent with the client level data that needs to be uploaded to HRSA with the RSR, so monitoring the performance measures in CAREWare will assist the grantee with preparation for the RSR collection that began in January of 2009.
A QI formal meeting process has now been in place for over a year and provides a structured environment for the discussion of quality improvement issues. The Quality Committee meets monthly and minutes are recorded. In addition, the Manager of Quality Assurance and Data Analysis continues to utilize the skills gained from the Train-the-Trainer Program from the National Quality Center, and has conducted four quality improvement trainings to date. All members of the Quality Committee (QC) have been trained in PDSA, QI Theories and Principles, Performance Measurement, RW Quality Expectations, and Leadership for Quality Improvement.
Although performance measures have always been tracked, the quality management plan was primarily the responsibility of the Manager of Quality Assurance and Data Analysis and attention was more focused on measurement rather than process. With the implementation of Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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quality committee meetings, other staff have become involved in the process and are trained in quality improvement activities as well so that formal PDSA cycles and improvement projects are not the responsibility of one or two individuals. This has also created a sense of teamwork and allows staff to present concerns so that the group can process possible solutions. Based on the work and feedback from the QC, technical assistance requests for case management are efficient and providers are satisfied with the training they are receiving.
Medical case management quality improvement visits are assisting case managers with performance improvement. During 2008, each medical case management site received a report detailing areas of strength and areas for improvement in CAREWare documentation, medical case management chart documentation, preparation for the RDR and RSR, and client satisfaction. The Coordinator of Case Management Services, Director of Care Delivery, Contract Monitor, and Manager of Care QA and Data Analysis have been conducting these team visits along with CDC funded prevention quality assurance staff. The team has been a great asset to assist case managers with evaluating their services and providing recommendations for improvement. The QC also partnered with a pharmaceutical company in December of 2008 to conduct medication adherence behavioral change training for case managers and medication adherence staff. This training was a great opportunity for case managers to improve motivational interviewing skills.
Clinical quality progress reports and results of QI studies are presented to the Oklahoma HIV Planning Council’s Evaluation and Assessment Committee for review. In addition, the Manager of Quality Assurance and Data Analysis has provided quality improvement training to the OHPC on Quality Management Expectations of Ryan White Grantees and Client Satisfaction. Performance measure data has been an integral piece to the collaboration of Ryan White Parts B, C and D in Oklahoma. Since all Parts use CAREWare and data is stored centrally by the OSDH, performance measures are calculated for clients receiving Parts B through D statewide. OSDH is also currently collaborating with a Part C and D clinic to establish a Statewide “Consumers for Quality Group” that will report to the Quality Committee. Based on QM data statewide on the increasing caseloads of medical case managers, OSDH increased Part B funding to support more medical case managers at the Part C clinics in Oklahoma City and Tulsa.
Planned Quality Activities
Goals and Objectives for FY 2009
1. Goal: Improve performance measure data and clinical client data documentation in CAREWare.
• Objective: By April of 2009, provide training on performance measures, RDR reporting, and RSR data collection.
2. Goal: Improve efficiency and completeness of client level data reporting/ application process for the HIV Drug Assistance Program and Health Insurance Assistance Program. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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• Objective: By March of 2010, have online case management system in place that will include an online application process.
3. Goal: Complete data collection and analysis on quality improvement projects.
• Objective: By March of 2010, conduct quality improvement projects (dental care exams and updated care plans) using Plan, Do, Study, Act methodology and implement positive changes.
4. Goal: Implement a consumer advisory process for Part B services to assist with quality improvement activities.
• Objective: By March of 2010, conduct quality improvement training for consumers and form committee of Consumers for Quality that reports to the overall Quality Committee.
5. Goal: Improve treatment adherence outcomes of new HIV Drug Assistance Program clients.
• Objective: By March of 2010, conduct evaluation of adherence counseling and education program with clients of HIV Drug Assistance Program.
6. Goal: Update and improve current case management standards.
• Objective: By March of 2010, establish workgroup, process and timeline for revising case management standards.
7. Goal: Update and improve current provider quality management plans.
• Objective: By March of 2010, conduct at least 1 site visit per agency to review quality management plans and make recommendations for improvements.
CHAPTER 16: Using Data for Evaluation
Using Data to Improve or Change Service Delivery in the State
A comprehensive system of program data tracking and program evaluation has been developed and will continue throughout the next project period to capture and report the required administrative and clinical program data. Both formative (monthly/quarterly) and summative (biannual) evaluations will continue to be performed in compliance with the goals and objectives of the comprehensive plan. Annual budget period renewal applications, delineating progress toward the stated goals and objectives will be submitted each year, and the Data Reports will be submitted each year, according to HRSA/HAB’s requirements.
OSDH has developed a thoughtful, planned and systematic process for monitoring and evaluating the quality, comprehensiveness, accessibility and clinical outcomes of the Ryan White Part B funded service categories. Performance progress data is collected monthly according to a Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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service-specific (i.e., EIS/case finding, primary medical care, medical case management and treatment adherence, referrals, etc) management information system that, together, captures all relevant program services data on an ongoing basis. These data reports form the basis for the annual OHPC planning activities, OSDH narrative progress reports and the annual data reports.
Multiple sources of data are used to evaluate the State’s level of progress toward achievement of the five key Health Resources and Services Administration (HRSA) goals: 1) improve access to care, 2) eliminate health disparities, 3) improve the quality of care, 4) assure cost effectiveness, and 5) improve health outcomes. Examples of the types of data to be used to evaluate attainment of these goals include the following:
Improving access to care and reducing access disparities: Individual level client data will be gathered and tracked regarding testing/referral source and length of time between testing and care entry. Each provider will track and report the number of new and returning patients by demographic profile, compared to the evolving profile of the local epidemic to evaluate the level of access and whether access is increasing, especially among the underserved and hard-to-reach populations in the urban and rural portions of the state.
Needs assessment data will be analyzed for the generation and testing of new interventions and strategies to reduce the stated barriers to access and retention in care among PLWHA. Provider and PLWHA-identified service gaps will be addressed through the annual planning processes, with ongoing monitoring of the state’s level of success in reducing gaps in the core medical and key supportive services. Individual level client data and aggregate provider data by service category will be tracked and analyzed to determine the degree to which Oklahoma is reducing access disparities among each of the special populations.
Individual level client data will be tracked and evaluated for the number and proportion of PLWHA who are present and retained in primary medical care (evidenced by making and keeping at least one primary medical care visit during the initial six month time period and achieving at least one PMC visit during the second six month period of each project year) as a key measure of retention in care. Routine analyses of the Medical and non-Medical Case Manager’s initial and annual client assessments of support service needs compared to level and extent of confirmed referrals and service usage will be used to examine the extent of confirmed access to medical services and the degree to which the supportive services are contributing to PLWHA engagement with and their sustained retention in care.
Reducing level of unmet need: Individual level client data will be tracked regarding dates of previous testing, previous medical care and length of absence from care upon entry into care and upon re-entry into HIV medical care. OSDH will perform a cross-match of PEMS data to CAREWare data to evaluate length of delays from testing and entry into care. Multiple strategies are outlined to aggressively reduce the high level of unmet need in the state of Oklahoma and expand services to assure all PLWHA of access to core medical services and key supportive services to maximize utilization of services and retention in care. The OSDH will utilize data from multiple sources to evaluate progress in reducing the out of care fraction in Oklahoma. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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Ensuring cost-effectiveness of services delivery: Key data elements that are tracked and analyzed on a monthly, quarterly and annual basis include provider reports of cost expenditures by client and by service category; continual evaluation of the other local resources available; maximal use of non-Ryan White sources of care and funding to support the Oklahoma continuum of care; and analysis of individual client level data for evidence of duplicative service delivery, with actions taken to prevent or reduce any unnecessary duplication.
Improving the quality of the care and services delivered: A robust quality management system ensures the continued progress toward achieving the highest level of quality possible, according to HRSA/HAB performance measures, as discussed at length in the following chapter.
Improving the health outcomes of individual PLWHA: The plans to utilize client level data along with aggregate provider data, by service category, in order to demonstrate how Part B funded services are improving HIV-related clinical health outcomes, are comprehensively discussed in the following chapter.
CHAPTER 17: Clinical Quality Management
CQM Program Structure
Purpose, Vision, Mission
The purpose of the Quality Management (QM) Program is to set forth a coordinated approach to ensuring Part B clients have access to high quality services that are consistent with Public Health Service Guidelines for the treatment of HIV/AIDS. The mission of the QM Program is to improve the quality and availability of health care and support services to eligible individuals and families living with HIV disease. Quality Improvement (QI) principles will be utilized as a basis for improvement of care and services. The QM Program strives to continuously improve the quality of care and services in a multidisciplinary team approach and are consistent with the overall commitment to quality within the Oklahoma State Department of Health and HIV/STI Service.
Overall Goals and Objectives
A systematic, program-wide process for planning, designing, measuring, assessing and improving performance will include the following components:
A. Develop a planning mechanism incorporating baseline data from external and internal sources (list data sources) and input from department leadership, staff and clients. Clinical, operational and programmatic aspects of client care will be reviewed.
B. Emphasize design needs associated with new and existing services, patient care delivery, work flows and support systems which maximize results and satisfaction on the part of the clients and their families, providers and staff. Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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C. Evolve and refine measurement systems for identifying trends in care and sentinel events by regularly collecting and recording data and observations relating to the provision of client care across the continuum.
D. Employ assessment procedures to determine efficacy and appropriateness and to judge how well services are delivered and whether opportunities for improvement exist.
E. Focus on improving quality in all of its dimensions by implementing multidisciplinary, data driven, project teams and encouraging participatory problem solving.
F. Promote communication, dialogue and informational exchange across the department and throughout the organizations reporting structure, with regard to findings, analyses, conclusions, recommendations, actions and evaluations pertaining to performance improvement.
G. Strive to establish collaborative relationships with diverse community and healthcare agencies for the purpose of collectively promoting the general health and welfare of the community served
FY 2008 Part B funds allocated to clinical quality management
Oklahoma allocated 3.5% of its FY08 Part B funds to quality management.
QM Program Roles and Responsibilities
The department’s leadership group, Director of Care Delivery, Contract Monitor, Manager of HIV Drug Assistance, Health Insurance Assistance, and Home Health Programs, Coordinator of Health Insurance Assistance, Manager of Quality Assurance and Data Analysis, Coordinator of Case Management Services, and HDAP Enrollment Coordinator, is accountable, responsible and answerable for planning, directing, coordinating and improving healthcare services in the Ryan White Part B Program. This leadership group approves the performance improvement plan, and reviews quality improvement activities during its regular meetings.
The leadership group has formed a Quality Committee (QC), under the direction of the Director of Care Delivery. The QC, Director of Care Delivery, and HIV/STI Service Chief oversee the allocation of resources to quality management activities. The Manager of Quality Assurance and Data Analysis serves as the QC leader and coordinates the QC activities and agenda topics, including establishing the quality management program and coordinating the QI plan and improvement projects. The Director of Care Delivery serves as the QC facilitator, providing support and feedback to the QC leader. QC member responsibilities include suggesting problem-solving tools, offering ideas and active participation in improvement projects, respecting meeting ground rules, reviewing QI plan goals and indicators, regular meeting attendance, and rotating meeting minute responsibilities.
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The Oklahoma HIV Planning Council (OHPC) members (providers and consumers) provide ongoing quality improvement feedback through the Evaluation and Assessment Committee. The Manager of Quality Assurance and Data Analysis reports quality activities to this committee and provides quality training to OHPC members, QC members, and contracted providers. In addition, the Manager of Quality Assurance and Data Analysis reports member recommendations and concerns to the QC. Through the Division of Care Delivery, the QC also provides ongoing QI reports to the HIV/STD Service Chief and HIV community and medical providers.
Process for Evaluation of QM Program and Activities
Once an opportunity for improvement has been identified, a multidisciplinary improvement project team will be convened to analyze the process and develop improvement plans. These teams will include those staff members closely associated with the process under study. Every attempt will be made to include individuals from other areas who may be impacted by changes made by the team and to help promote collaboration between agencies.
Continuous Quality Improvement Methodology will be utilized and will include but not be limited to the following:
• PDSA (Plan/Do/Study/Act) • Flow Chart Analysis • Cause-and-Effect
Diagrams • Brainstorming • Observational Studies/patient flow • Activity Logs
Quality Committee/Team Meeting Record Improvement Plans will be developed and implemented by the teams. Improvements may include:
• System Redesign • Education or Technical Assistance (Internal or Provider Staff/Patients) • Clinical Guidelines review, revision or development• Procedure and policy changes • Form development or revision
All improvement plans will be communicated to all staff and to providers/ clients if deemed appropriate. Meetings, e-mails, memos, and informal verbal communications are all considered appropriate methods to communicate the team’s activities and improvement plans, as long as all parties are included in the process.
Specific Indicators Being Monitored for Core Medical Services and Data Collection Strategy
The QC will be monitoring core medical services in accordance with the HAB performance measures for core medical, Groups 1, 2, and 3. Once approved Group 3 (in draft form) performance indicators (HDAP, Case Management, and Dental) will be measured as well. OSDH also measures indicators associated with satisfaction and health status. Indicators will be analyzed using data from Ryan White CAREWare, EMR, the new Ryan White Services Report, HDAP/HIAP enrollment database, medical case management chart reviews, and client satisfaction surveys.
The QC will monitor progress toward indicators by reviewing data quarterly. The QC has established baselines for the core medical performance measures deemed critical by HAB Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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(Group 1). Complete data for 2007 was not available in CAREWare for PCP prophylaxis, and will be a measure the QC and medical providers will work toward standardizing for data collection procedures as an improvement project.
Performance indicators include the following for 2009. Baseline data is included with dates of reporting period and data source.
Table 41: 2009 Performance Indicators
Indicator
Baseline Percentage
Reporting Period
Data Source
Percentage of clients with HIV infection who had two or more CD4 t‐cell counts performed in the measurement year.
73%
1/1/2007 thru 12/31/2007
CAREWare
Percentage of clients with AIDS who are prescribed HAART.
100%
1/1/2007 thru 12/31/2007
RDR, CAREWare
Percentage of clients with HIV infection who had two or more medical visits in an HIV care setting in the measurement year.
86%
1/1/2007 thru 12/31/2007
RDR, CAREWare
Percentage of clients with HIV infection and a CD4 T‐cell count below 200 cells/mm3 that were prescribed PCP prophylaxis.
Insufficient Data
1/1/2007 thru 12/31/2007
CAREWare
Percentage of pregnant women with HIV infection who are prescribed antiretroviral therapy.
95%
1/1/2007 thru 12/31/2007
RDR, CAREWare
Percentage of women with HIV infection who have a Pap screening in the measurement year.
77%
1/1/2007 thru 12/31/2007
RDR, CAREWare
Percentage of clients with HIV infection for whom Hepatitis C (HCV) screening was performed at least once since the diagnosis of HIV infection.
18%
1/1/2007 thru 12/31/2007
RDR, CAREWare
Percentage of clients with HIV infection who received an oral exam by a dentist at least once during the measurement year.
38%
1/1/2007 thru 12/31/2007
CAREWare
Percentage of adult clients with HIV infection who had a test for syphilis performed in the measurement year.
60%
1/1/2007 thru 12/31/2007
RDR, CAREWare
Percentage of clients with HIV infection who received testing with results documented for latent tuberculosis infection since HIV diagnosis.
52%
1/1/2007 thru 12/31/2007
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Indicator
Baseline Percentage
Reporting Period
Data Source
Percentage of HIV positive clients satisfied with Ryan White medical case management services in the measurement year.
89%
1/1/2008 thru 12/31/2008
Case Management Client Satisfaction Survey
Percentage of HIV‐infected medical case management clients who had a medical case management care plan documented and updated two or more times in the year.
71%
1/1/2008 thru 12/31/2008
Medical Case Management Chart Review
Percentage of HIV‐infected medical case management clients who had 2 or more medical visits in an HIV care setting in the measurement year.
49%
1/1/2007 thru 12/31/2007
CAREWare
Percentage of HDAP applications approved or denied for HDAP enrollment within 2 weeks of HDAP receiving a complete application.
99%
4/1/2007 thru 3/31/2008
HDAP/HIAP enrollment/ chart review
Percentage of clients enrolled in HDAP or Health Insurance Assistance that rate their health as good or very good in the measurement year.
68%
4/1/2007 thru 3/31/2008
HDAP/HIAP enrollment
Percentage of HDAP or Health Insurance Assistance clients stating their health had improved after being on ART for a year or more in the measurement year.
76%
4/1/2007 thru 3/31/2008
HDAP/HIAP enrollment
Percentage of HDAP or Health Insurance Assistance clients that had undetectable viral loads in the measurement year.
73%
4/1/2007 thru 3/31/2008
HDAP/HIAP enrollment
✓Annual Quality Goals
Based on last year’s performance rates, the quality committee prioritizes the following 2009 quality projects. Quality improvement project teams will be initiated in order to improve the following:
1. Percentage of clients with HIV infection and a CD4 T-cell count below 200 cells/mm3 prescribed PCP prophylaxis. Data entry issue in CAREWare. Goal is 90%.
2. Percentage of clients with HIV infection who received an oral exam by a dentist at least once during the measurement year. Possible data entry issue. Goal is 50%.
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3. Percentage of HIV-infected medical case management clients who had a medical case management care plan documented and updated two or more times in the measurement year. Documentation issue in case management charts. Also need to record in CAREWare for RSR. Goal is 80%.
✓ Regular review of data for performance measures from a variety of sources will occur quarterly. The Manager of Quality Assurance and Data Analysis will coordinate these activities. Data reports will be presented for review to Quality Committee and designated teams. Data sources will include but will not be limited to:
• Clinical Measures utilizing RW CAREWare
• Client Satisfaction Survey results
• Demographic data, visit frequency, referral data from CAREWare
• Drug utilization pattern, adherence, and pharmacy data from OU College of Pharmacy system.
• Quality of Life data from HIV Drug Assistance Program and Health Insurance Assistance Program enrollment data.
• Chart Audit data from case management and mental health.
Data collection will be implemented utilizing appropriate sampling methodology and will include both concurrent and retrospective review.
Assessment and Evaluation
Assessment and evaluation of the data will be performed by various existing teams (Contracts and Administration, HDAP/HIAP, Quality Assurance and Data Analysis, Senior Management, OHPC Assessment and Evaluation Committee) who will determine if the data warrants further evaluation. Based on this ongoing review, priorities will be set and opportunities for improvement identified.
Multidisciplinary Team and Development of Improvement Plan
Once an opportunity for improvement has been identified a multidisciplinary team will be convened to analyze the process and develop improvement plans. These teams will include those staff members closely associated with the process under study. Every attempt will be made to include individuals from other areas who may be impacted by changes made by the team and to help promote collaboration between agencies.
Continuous Quality Improvement Methodology will be utilized and will include but not be limited to the following:
• PDSA (Plan/Do/Study/Act) Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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• Flow Chart Analysis
• Cause-and-Effect Diagrams
• Brainstorming
• Observational Studies/patient flow
• Activity Logs
Quality Committee/Team Meeting Record Improvement Plans will be developed and implemented by the teams. Improvements may include: • System Redesign• Education (Staff/Patients) • Clinical Guidelines review, revision or development• Procedure and policy changes• Form development or revision
All improvement plans will be communicated to all staff and to providers/ clients if deemed appropriate. Regular meetings, e-mail, memos, and informal verbal communication are all considered appropriate methods to communicate the team’s activities and improvement plans, as long as all parties are included in the process.
F. Sustaining Improvements
Regular feedback regarding improvement projects is critical to its success in sustaining improvements over time. Once an improvement plan has been successful a regular monitoring schedule will be implemented to determine whether the plan remains successful over time.
Description of HDAP Quality Management Program
Improvements and changes needed in program service delivery can be determined based on review of data. The Advisory Committee’s primary purpose is to make HDAP formulary recommendations and uses guidelines for formulary changes. These guidelines include a review of clinical information, cost consideration of the drug, and program budget implications. The grantee takes into consideration the cost neutrality of the drug as compared to other drugs already in the existing class of drugs and data, if available, to project program utilization and cost. This committee consists of Infectious Disease physicians, HIV specialists and clinical pharmacists involved in the care of HDAP patients, including physicians connected with the Part C clinics. This committee has managed effectively by meeting electronically and by conference call on an as needed basis. If further communication is needed, meetings can be scheduled. This process has helped to expedite the addition of new FDA approved antiretroviral drugs to the program formulary.
The grantee is linked with AETC who provides workshops for Ryan White providers including HDAP prescribing physicians. The information presented in these workshops is continually updated with the latest guidelines. Members of the Advisory Committee are also part of the AETC as consulting physicians for health care practitioners statewide. The HDAP manager also presents jointly with AETC staff to health care providers on HDAP.Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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APPENDICES
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AIDS Incidence
AIDS Prevalence
HIV (not aids) Prevalence
01/01/06 to 12/31/07
as of 12/31/07
as of 12/31/07
Demographic Group/Exposure Category
AIDS incidence is defined as the number of new AIDS cases diagnosed during the period specified.
AIDS Prevalence is defined as the number of people living with AIDS as of the date specified.
HIV Prevalence is defined as the estimated number of diagnosed people living with HIV (not AIDS) as of the date specified.
Race/Ethnicity
Number
% of Total
Number
% of Total
Number
% of Total
White, not Hispanic
229
51.3
1,532
47.9
1,137
40.5
Black, not Hispanic
116
26.0
462
14.5
430
15.3
Hispanic
47
10.5
122
3.8
96
3.4
Asian/Pacific Islander
3
0.7
0
0.0
2
0.1
American Indian/Alaska
32
7.2
151
4.7
99
3.5
Multi- Race
19
4.3
0
0.0
0
0.0
Unknown
0
0.0
928
29.0
1,046
37.2
Total
446
100.0
3,195
100.0
2,810
100.0
Gender
#
% of Total
#
% of Total
#
% of Total
Male
370
83.0
2,738
85.7
2,273
80.9
Female
76
17.0
457
14.3
537
19.1
Total
446
100.0
3,195
100.0
2,810
100.0
Age at Diagnosis (Years)
#
% of Total
#
% of Total
#
% of Total
<13
1
0.2
11
0.3
37
1.3
13-14
1
0.2
2
0.1
2
0.1
15-24
24
5.4
180
5.6
610
21.7
25-34
108
24.2
1,120
35.1
1,125
40.0
35-44
177
39.7
1,302
40.8
733
26.1
45-54
109
24.4
474
14.8
246
8.8
55-64
20
4.5
92
2.9
48
1.7
>=65
6
1.3
14
0.4
9
0.3
Total
446
100.0
3,195
100.0
2,810
100.0 Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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AIDS Incidence:
AIDS Prevalence
HIV (not aids) Prevalence
01/01/06 to 12/31/07
as of 12/31/07
as of 12/31/07
Demographic Group/
Exposure Category
AIDS incidence is defined as the number of new AIDS cases diagnosed during the period specified.
AIDS Prevalence is defined as the number of people living with AIDS as of the date specified.
HIV Prevalence is defined as the estimated number of diagnosed people living with HIV (not AIDS) as of the date specified.
Adult/Adolescent AIDS Exposure Category
Number
%
Number
%
Number
%
Male‐to‐male sexual contact
197
44
1,674
53
1,345
49
Injection drug use
57
13
384
12
330
12
Male‐to‐male sexual contact and injection drug use
40
9
412
13
250
9
Hemophilia/coagulation disorder
1
0
14
0
7
0
Heterosexual contact
58
13
343
11
336
12
Receipt of blood, components, or tissue
2
0
22
1
20
1
Perinatal exposure, HIV diagnosed >= 13
0
0
0
0
0
0
Other risk factor reported
0
0
0
0
0
0
Risk not specified
88
0
331
10
485
17
Total
443
100
3,180
100
2,773
100
Pediatric AIDS Exposure Categories
Number
%
Number
%
Number
%
Hemophilia/coagulation disorder
0
0
1
9
4
11
Mother with/at risk for HIV infection
1
100
9
82
27
73
Receipt of blood, components, or tissue
0
0
0
0
0
0
Other risk factor reported
0
0
1
9
6
16
No identified risk factor (NIR)f
0
0
0
0%
0
0%
No risk factor reported (NRR)g
0
0
0
0
0
0
Total
1
100
11
100
37
100 Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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State of Oklahoma Implementation Plan – Oklahoma State Department of Health
Ryan White Part B ‐ FY 2009 (April 1, 2009 – March 31, 2010)
Part B Program Area: Part B Base
Total Number of Contractors/Providers Funded in FY 2009: 5
Service Goal Statement: To link eligible Persons Living With HIV/AIDS in Oklahoma to appropriate outpatient medical care and support services to improve health status.
Quantity: Provide the number of people to be served and service units to be provided during the grant year.
Objective/s: List quantifiable and time‐limited objectives relating to the Program Area named above. Where appropriate, list multiple objectives that are required to implement a new service, or to continue an existing service.
Service Unit Definition: Provide the name and definition of the unit of service to be provided (e.g. a one‐hour face‐to‐face encounter, one round‐trip bus ride).
Number of People to be Served
Total number of Service Units to be Provided
Time Frame: Indicate the estimated duration of activity relating to the objective listed.
FY 2009 Funds: Provide the approximate amount of Part B funds to be used to provide this service. Where possible, divide funding among individual objectives.
1. Identify and link to primary medical care HIV+ individuals statewide who know their HIV status but are not in care.
One face to face outreach case management visit
120
300
Apr 09 –
Mar 10
$135,000
Comanche County $45,000
Oklahoma City $45,000
Tulsa $45,000
2. Coordinate medical care through clinical case management at Part C EIS clinics utilizing an interdisciplinary medical model.
One face to face clinical case management visit
1,000
2,000
Apr 09 –
Mar 10
$390,000:
$230,000 Oklahoma City
$160,000 Tulsa
3. Coordinate medical and social support services through community case management.
One community case management face to face visit
720
1,440
Apr 09 –
Mar 10
$315,000:
$135,000 OKC MSA
$135,000 Tulsa MSA
$45,000 Comanche County
4. Provide eligible Part B clients with HIV medications not covered on the ADAP formulary.
One prescription
500
3,500
Apr 09 –
Mar 10
$304,670 statewide:
$182,802 western Oklahoma
$121,868 eastern Oklahoma Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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Part B Program Area: Part B Base
5. Provide eligible Part B
clients with transportation services to medical appointments.
One bus token, cab voucher, or volunteer driver service
450
900
Apr 09 –
Mar 10
$35,000 statewide:
$25,067 western Oklahoma
$6,933 eastern Oklahoma
6. Provide eligible Part B clients with dental care services for diagnostic, prophylactic and therapeutic Class 1, 2, and 3 oral health care needs.
One dental visit
450
450
Apr 09 –
Mar 10
$133,630 statewide:
$80,462 western Oklahoma
$53,168 eastern Oklahoma
7. Provide eligible Part B clients with laboratory services in order to monitor HIV disease.
One laboratory service
550
1,050
Apr 09 –
Mar 10
$74,000 statewide:
$44,400 western Oklahoma
$29,600 eastern Oklahoma
One individual, group, or professional counseling session
8. Provide outpatient mental health and substance abuse services through individual therapy, group therapy, or professional counseling.
$147,626 statewide:
$97,626 western Oklahoma
1,200
Apr 09 –
250
Mar 10
$50,000 eastern Oklahoma
One laboratory, dental, or medical specialty service
$337,000
9. Provide specialty primary care services to eligible Part B clients.
$224,000 western Oklahoma
Apr09‐
150
1,200
Mar10
$113,000 eastern Oklahoma
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Part B Program Area: ADAP (HIV Drug Assistance Program)
Total Number of Contractors/Providers Funded in FY 2009: 3
Service Goal Statement: To ensure access to HIV/AIDS therapies consistent with PHS guidelines for all eligible Persons Living With HIV/AIDS in Oklahoma.
Quantity:
Objective/s:
Service Unit Definition
Number of People to be Served
Total number of Service Units to be Provided
Time Frame:
FY 2009 Funds Total = $4,278,905 (does not include Administration, Quality Management, Planning and Evaluation):
ADAP Earmark
$3,795,618
Part B Base
$480,287
1. Continue statewide HIV prescription assistance program through the state’s AIDS Drug Assistance Program
One prescription for medication on the program formulary
570
15,321
Apr 09 ‐ Mar 10
$3,869,405
2. Continue prescription co‐pay assistance for medications on the state’s AIDS Drug Assistance Program
One prescription that receives co��pay assistance
300
5,100
Apr 09 ‐ Mar 10
$409,500
3. Provide clinical adherence services to ADAP clients in the Oklahoma City Part C clinic
One service of either initial assessment, follow‐up and routine clinical visit and refill monitoring.
660
2472
Apr 09‐Mar 10
$204,224 Oklahoma State Department of Health 2009‐2011 Comprehensive Plan
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Part B Program Area: Health Insurance Assistance Program
Total Number of Contractors/Providers Funded in FY 2009: 1
Service Goal Statement: To ensure access to continued health insurance coverage for all eligible Persons Living With HIV/AIDS in Oklahoma.
Quantity:
Service Unit Definition
Number of People to be Served
Total number of Service Units to be Provided
Time Frame:
Objective/s:
FY 2009 Funds
1. Continue
statewide health insurance assistance through the state’s HIV Insurance Assistance Program.
One monthly insurance premium payment
160
1,440
Apr 09‐ Mar 10
$775,600
Part B Program Area: HIV Home Health Program
Total Number of Contractors/Providers Funded in FY 2009: 1
Service Goal Statement: To ensure access to continued health insurance coverage for all eligible Persons Living With HIV/AIDS in Oklahoma.
Quantity:
Time Frame:
FY 2009 Funds
Objective/s:
Service Unit Definition
Number of People to be Served
Total number of Service Units to be Provided
1. Continue statewide HIV Home Health Program.
One skilled nurse visit, personal care visit or DME
15
100
Apr 09 ‐ Mar 10
$25,000